|
ALPROSTADIL 500 MCG/ML INJECTION SOLUTION [9001]
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
NDC 00009316906
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$259.25 |
| Max. Negotiated Rate |
$295.85 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$274.50
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
|
|
ALTEPLASE 100 MG/100ML IV (WET SOLR VIAL) [4309002]
|
Facility
|
IP
|
$11,061.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,401.85 |
| Max. Negotiated Rate |
$10,729.17 |
| Rate for Payer: Cash Price |
$6,636.60
|
| Rate for Payer: Health Management Network Commercial |
$9,401.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,954.90
|
| Rate for Payer: MDX Hawaii PPO |
$10,729.17
|
|
|
ALTEPLASE 100 MG/100ML IV (WET SOLR VIAL) [4309002]
|
Facility
|
OP
|
$11,061.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$10,729.17 |
| Rate for Payer: AlohaCare Medicaid |
$5,530.50
|
| Rate for Payer: AlohaCare Medicare |
$3,428.91
|
| Rate for Payer: Cash Price |
$6,636.60
|
| Rate for Payer: Cash Price |
$6,636.60
|
| Rate for Payer: Devoted Health Medicare |
$3,760.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,428.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,507.95
|
| Rate for Payer: Health Management Network Commercial |
$9,401.85
|
| Rate for Payer: Humana Medicare |
$3,428.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,954.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,641.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,428.91
|
| Rate for Payer: MDX Hawaii PPO |
$10,729.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,428.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,428.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,636.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,428.91
|
| Rate for Payer: University Health Alliance Commercial |
$8,062.36
|
|
|
ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]
|
Facility
|
OP
|
$11,061.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$10,729.17 |
| Rate for Payer: AlohaCare Medicaid |
$5,530.50
|
| Rate for Payer: AlohaCare Medicare |
$3,428.91
|
| Rate for Payer: Cash Price |
$6,636.60
|
| Rate for Payer: Cash Price |
$6,636.60
|
| Rate for Payer: Devoted Health Medicare |
$3,760.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,428.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,507.95
|
| Rate for Payer: Health Management Network Commercial |
$9,401.85
|
| Rate for Payer: Humana Medicare |
$3,428.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,954.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,641.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,428.91
|
| Rate for Payer: MDX Hawaii PPO |
$10,729.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,428.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,428.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,636.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,428.91
|
| Rate for Payer: University Health Alliance Commercial |
$8,062.36
|
|
|
ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]
|
Facility
|
IP
|
$11,061.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,401.85 |
| Max. Negotiated Rate |
$10,729.17 |
| Rate for Payer: Cash Price |
$6,636.60
|
| Rate for Payer: Health Management Network Commercial |
$9,401.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,954.90
|
| Rate for Payer: MDX Hawaii PPO |
$10,729.17
|
|
|
ALTEPLASE 10 MG (1 MG/ML) SYRINGE FOR CT (SIMPLE) [4080500]
|
Facility
|
IP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,347.25 |
| Max. Negotiated Rate |
$1,537.45 |
| Rate for Payer: Cash Price |
$951.00
|
| Rate for Payer: Health Management Network Commercial |
$1,347.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,426.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,537.45
|
|
|
ALTEPLASE 10 MG (1 MG/ML) SYRINGE FOR CT (SIMPLE) [4080500]
|
Facility
|
OP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$1,537.45 |
| Rate for Payer: AlohaCare Medicaid |
$792.50
|
| Rate for Payer: AlohaCare Medicare |
$491.35
|
| Rate for Payer: Cash Price |
$951.00
|
| Rate for Payer: Cash Price |
$951.00
|
| Rate for Payer: Devoted Health Medicare |
$538.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$491.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,505.75
|
| Rate for Payer: Health Management Network Commercial |
$1,347.25
|
| Rate for Payer: Humana Medicare |
$491.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,426.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$808.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$491.35
|
| Rate for Payer: MDX Hawaii PPO |
$1,537.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$491.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$491.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$951.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$491.35
|
| Rate for Payer: University Health Alliance Commercial |
$1,155.31
|
|
|
ALTEPLASE 2 MG/2ML IJ (WET SOLR VIAL) [43031310]
|
Facility
|
IP
|
$1,667.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,416.95 |
| Max. Negotiated Rate |
$1,616.99 |
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Health Management Network Commercial |
$1,416.95
|
| Rate for Payer: Health Management Network Commercial |
$283.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,500.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$300.60
|
| Rate for Payer: MDX Hawaii PPO |
$323.98
|
| Rate for Payer: MDX Hawaii PPO |
$1,616.99
|
|
|
ALTEPLASE 2 MG/2ML IJ (WET SOLR VIAL) [43031310]
|
Facility
|
OP
|
$1,667.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$1,616.99 |
| Rate for Payer: AlohaCare Medicaid |
$833.50
|
| Rate for Payer: AlohaCare Medicaid |
$167.00
|
| Rate for Payer: AlohaCare Medicare |
$103.54
|
| Rate for Payer: AlohaCare Medicare |
$516.77
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$1,000.20
|
| Rate for Payer: Devoted Health Medicare |
$566.78
|
| Rate for Payer: Devoted Health Medicare |
$113.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$516.77
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,583.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$317.30
|
| Rate for Payer: Health Management Network Commercial |
$283.90
|
| Rate for Payer: Health Management Network Commercial |
$1,416.95
|
| Rate for Payer: Humana Medicare |
$516.77
|
| Rate for Payer: Humana Medicare |
$103.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,500.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$300.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$170.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$850.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$516.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.54
|
| Rate for Payer: MDX Hawaii PPO |
$1,616.99
|
| Rate for Payer: MDX Hawaii PPO |
$323.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$516.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$516.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$200.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,000.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$516.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.54
|
| Rate for Payer: University Health Alliance Commercial |
$1,215.08
|
| Rate for Payer: University Health Alliance Commercial |
$243.45
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]
|
Facility
|
OP
|
$334.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$323.98 |
| Rate for Payer: AlohaCare Medicaid |
$167.00
|
| Rate for Payer: AlohaCare Medicare |
$103.54
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Devoted Health Medicare |
$113.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.54
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$317.30
|
| Rate for Payer: Health Management Network Commercial |
$283.90
|
| Rate for Payer: Humana Medicare |
$103.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$300.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$170.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.54
|
| Rate for Payer: MDX Hawaii PPO |
$323.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$200.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.54
|
| Rate for Payer: University Health Alliance Commercial |
$243.45
|
|
|
ALTEPLASE 2 MG INTRA-CATHETER SOLUTION [31310]
|
Facility
|
IP
|
$334.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$283.90 |
| Max. Negotiated Rate |
$323.98 |
| Rate for Payer: Cash Price |
$200.40
|
| Rate for Payer: Health Management Network Commercial |
$283.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$300.60
|
| Rate for Payer: MDX Hawaii PPO |
$323.98
|
|
|
ALTEPLASE 2 MG SYRINGE (SIMPLE) [4080428]
|
Facility
|
OP
|
$317.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: AlohaCare Medicaid |
$158.50
|
| Rate for Payer: AlohaCare Medicare |
$98.27
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Devoted Health Medicare |
$107.78
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$301.15
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Humana Medicare |
$98.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$161.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.27
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$190.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.27
|
| Rate for Payer: University Health Alliance Commercial |
$231.06
|
|
|
ALTEPLASE 2 MG SYRINGE (SIMPLE) [4080428]
|
Facility
|
IP
|
$317.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$269.45 |
| Max. Negotiated Rate |
$307.49 |
| Rate for Payer: Cash Price |
$190.20
|
| Rate for Payer: Health Management Network Commercial |
$269.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$285.30
|
| Rate for Payer: MDX Hawaii PPO |
$307.49
|
|
|
ALTEPLASE 50 MG/50ML IV (WET SOLR VIAL) [4309003]
|
Facility
|
IP
|
$3,141.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,669.85 |
| Max. Negotiated Rate |
$3,046.77 |
| Rate for Payer: Cash Price |
$1,884.60
|
| Rate for Payer: Cash Price |
$3,468.60
|
| Rate for Payer: Health Management Network Commercial |
$2,669.85
|
| Rate for Payer: Health Management Network Commercial |
$4,913.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,826.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,202.90
|
| Rate for Payer: MDX Hawaii PPO |
$5,607.57
|
| Rate for Payer: MDX Hawaii PPO |
$3,046.77
|
|
|
ALTEPLASE 50 MG/50ML IV (WET SOLR VIAL) [4309003]
|
Facility
|
OP
|
$3,141.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$3,046.77 |
| Rate for Payer: AlohaCare Medicaid |
$1,570.50
|
| Rate for Payer: AlohaCare Medicaid |
$2,890.50
|
| Rate for Payer: AlohaCare Medicare |
$1,792.11
|
| Rate for Payer: AlohaCare Medicare |
$973.71
|
| Rate for Payer: Cash Price |
$3,468.60
|
| Rate for Payer: Cash Price |
$1,884.60
|
| Rate for Payer: Cash Price |
$3,468.60
|
| Rate for Payer: Cash Price |
$1,884.60
|
| Rate for Payer: Devoted Health Medicare |
$1,067.94
|
| Rate for Payer: Devoted Health Medicare |
$1,965.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,792.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$973.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,983.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,491.95
|
| Rate for Payer: Health Management Network Commercial |
$4,913.85
|
| Rate for Payer: Health Management Network Commercial |
$2,669.85
|
| Rate for Payer: Humana Medicare |
$973.71
|
| Rate for Payer: Humana Medicare |
$1,792.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,826.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,202.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,948.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,601.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$973.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,792.11
|
| Rate for Payer: MDX Hawaii PPO |
$3,046.77
|
| Rate for Payer: MDX Hawaii PPO |
$5,607.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,792.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$973.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$973.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,792.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,468.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,884.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$973.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,792.11
|
| Rate for Payer: University Health Alliance Commercial |
$2,289.47
|
| Rate for Payer: University Health Alliance Commercial |
$4,213.77
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]
|
Facility
|
IP
|
$5,781.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,913.85 |
| Max. Negotiated Rate |
$5,607.57 |
| Rate for Payer: Cash Price |
$3,468.60
|
| Rate for Payer: Health Management Network Commercial |
$4,913.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,202.90
|
| Rate for Payer: MDX Hawaii PPO |
$5,607.57
|
|
|
ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]
|
Facility
|
OP
|
$5,781.00
|
|
|
Service Code
|
HCPCS J2997
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$5,607.57 |
| Rate for Payer: AlohaCare Medicaid |
$2,890.50
|
| Rate for Payer: AlohaCare Medicare |
$1,792.11
|
| Rate for Payer: Cash Price |
$3,468.60
|
| Rate for Payer: Cash Price |
$3,468.60
|
| Rate for Payer: Devoted Health Medicare |
$1,965.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,792.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,491.95
|
| Rate for Payer: Health Management Network Commercial |
$4,913.85
|
| Rate for Payer: Humana Medicare |
$1,792.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,202.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,948.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,792.11
|
| Rate for Payer: MDX Hawaii PPO |
$5,607.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,792.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,792.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,468.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,792.11
|
| Rate for Payer: University Health Alliance Commercial |
$4,213.77
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00121176130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00536129383
|
|
Hospital Revenue Code
|
637
|
| 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 46122043440
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00536129383
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 57237031603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 46122043440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00121176130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP [9009]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 57237031603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
