|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [36576]
|
Facility
|
IP
|
$701.00
|
|
|
Service Code
|
NDC 00781618667
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$595.85 |
| Max. Negotiated Rate |
$679.97 |
| Rate for Payer: Cash Price |
$420.60
|
| Rate for Payer: Health Management Network Commercial |
$595.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$630.90
|
| Rate for Payer: MDX Hawaii PPO |
$679.97
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [36576]
|
Facility
|
OP
|
$673.00
|
|
|
Service Code
|
NDC 43598032675
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$208.63 |
| Max. Negotiated Rate |
$652.81 |
| Rate for Payer: AlohaCare Medicaid |
$336.50
|
| Rate for Payer: AlohaCare Medicare |
$208.63
|
| Rate for Payer: Cash Price |
$403.80
|
| Rate for Payer: Devoted Health Medicare |
$228.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$208.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$639.35
|
| Rate for Payer: Health Management Network Commercial |
$572.05
|
| Rate for Payer: Humana Medicare |
$208.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$605.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$343.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$208.63
|
| Rate for Payer: MDX Hawaii PPO |
$652.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$208.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$208.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$208.63
|
| Rate for Payer: University Health Alliance Commercial |
$490.55
|
|
|
CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION [36576]
|
Facility
|
IP
|
$673.00
|
|
|
Service Code
|
NDC 43598032675
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$572.05 |
| Max. Negotiated Rate |
$652.81 |
| Rate for Payer: Cash Price |
$403.80
|
| Rate for Payer: Health Management Network Commercial |
$572.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$605.70
|
| Rate for Payer: MDX Hawaii PPO |
$652.81
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [9610]
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
NDC 61314065605
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.02 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicare |
$44.02
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Devoted Health Medicare |
$48.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$44.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.02
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.02
|
| Rate for Payer: University Health Alliance Commercial |
$103.50
|
|
|
CIPROFLOXACIN 0.3 % EYE DROPS [9610]
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
NDC 61314065605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
|
CIPROFLOXACIN 250 MG TABLET [25118]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 65862007601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
CIPROFLOXACIN 250 MG TABLET [25118]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 55111012601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
CIPROFLOXACIN 250 MG TABLET [25118]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00143992701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
CIPROFLOXACIN 250 MG TABLET [25118]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 55111012601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
CIPROFLOXACIN 250 MG TABLET [25118]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 65862007601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
CIPROFLOXACIN 250 MG TABLET [25118]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00143992701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0744
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.32 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$9.30
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$10.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$9.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.30
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.30
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108132]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
CIPROFLOXACIN 500 MG TABLET [25119]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904724361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CIPROFLOXACIN 500 MG TABLET [25119]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904708361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CIPROFLOXACIN 500 MG TABLET [25119]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904708361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CIPROFLOXACIN 500 MG TABLET [25119]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904724361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CIPROFLOXACIN TABLETS (CIPRO) 500 MG (TAKE HOME) [4080346]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080134
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CIPROFLOXACIN TABLETS (CIPRO) 500 MG (TAKE HOME) [4080346]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080134
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CIRCL STR PASSER AR-7821
|
Facility
|
IP
|
$1,127.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.95 |
| Max. Negotiated Rate |
$1,093.19 |
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: Health Management Network Commercial |
$957.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,014.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,093.19
|
|
|
CIRCL STR PASSER AR-7821
|
Facility
|
OP
|
$1,127.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$349.37 |
| Max. Negotiated Rate |
$1,093.19 |
| Rate for Payer: AlohaCare Medicaid |
$563.50
|
| Rate for Payer: AlohaCare Medicare |
$349.37
|
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: Devoted Health Medicare |
$383.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$349.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,070.65
|
| Rate for Payer: Health Management Network Commercial |
$957.95
|
| Rate for Payer: Humana Medicare |
$349.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,014.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$574.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$349.37
|
| Rate for Payer: MDX Hawaii PPO |
$1,093.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$349.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$349.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$349.37
|
| Rate for Payer: University Health Alliance Commercial |
$821.47
|
|
|
CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC
|
Facility
|
IP
|
$34,130.88
|
|
|
Service Code
|
MSDRG 286
|
| Min. Negotiated Rate |
$34,130.88 |
| Max. Negotiated Rate |
$34,130.88 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$34,130.88
|
|
|
CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC
|
Facility
|
IP
|
$30,054.14
|
|
|
Service Code
|
MSDRG 287
|
| Min. Negotiated Rate |
$30,054.14 |
| Max. Negotiated Rate |
$30,054.14 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$30,054.14
|
|
|
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC
|
Facility
|
IP
|
$41,336.29
|
|
|
Service Code
|
MSDRG 433
|
| Min. Negotiated Rate |
$41,336.29 |
| Max. Negotiated Rate |
$41,336.29 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$41,336.29
|
|
|
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC
|
Facility
|
IP
|
$41,336.29
|
|
|
Service Code
|
MSDRG 432
|
| Min. Negotiated Rate |
$41,336.29 |
| Max. Negotiated Rate |
$41,336.29 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$41,336.29
|
|
