|
EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [160715]
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
634
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: AlohaCare Medicaid |
$53.00
|
| Rate for Payer: AlohaCare Medicare |
$32.86
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Devoted Health Medicare |
$36.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.70
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Humana Medicare |
$32.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.86
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.86
|
| Rate for Payer: University Health Alliance Commercial |
$77.26
|
|
|
EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]
|
Facility
|
IP
|
$2,055.00
|
|
|
Service Code
|
NDC 67457063110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,746.75 |
| Max. Negotiated Rate |
$1,993.35 |
| Rate for Payer: Cash Price |
$1,233.00
|
| Rate for Payer: Health Management Network Commercial |
$1,746.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,849.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,993.35
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [131638]
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 55150021910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$183.33 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$170.10
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
|
|
EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [131638]
|
Facility
|
IP
|
$469.00
|
|
|
Service Code
|
NDC 67457062910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$398.65 |
| Max. Negotiated Rate |
$454.93 |
| Rate for Payer: Cash Price |
$281.40
|
| Rate for Payer: Health Management Network Commercial |
$398.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: MDX Hawaii PPO |
$454.93
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 69452015120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 50268029711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 50268029711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 69452015120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]
|
Facility
|
OP
|
$2,538.00
|
|
|
Service Code
|
HCPCS J9179
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.95 |
| Max. Negotiated Rate |
$2,461.86 |
| Rate for Payer: AlohaCare Medicaid |
$1,269.00
|
| Rate for Payer: AlohaCare Medicaid |
$2,066.00
|
| Rate for Payer: AlohaCare Medicare |
$1,280.92
|
| Rate for Payer: AlohaCare Medicare |
$786.78
|
| Rate for Payer: Cash Price |
$2,479.20
|
| Rate for Payer: Cash Price |
$1,522.80
|
| Rate for Payer: Cash Price |
$1,522.80
|
| Rate for Payer: Cash Price |
$2,479.20
|
| Rate for Payer: Devoted Health Medicare |
$1,404.88
|
| Rate for Payer: Devoted Health Medicare |
$862.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$95.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$95.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$786.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,280.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$104.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,925.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,411.10
|
| Rate for Payer: Health Management Network Commercial |
$3,512.20
|
| Rate for Payer: Health Management Network Commercial |
$2,157.30
|
| Rate for Payer: Humana Medicare |
$1,280.92
|
| Rate for Payer: Humana Medicare |
$786.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,284.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,718.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,107.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,294.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$786.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,280.92
|
| Rate for Payer: MDX Hawaii PPO |
$2,461.86
|
| Rate for Payer: MDX Hawaii PPO |
$4,008.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$786.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,280.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,280.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$786.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,479.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,522.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,280.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$786.78
|
| Rate for Payer: University Health Alliance Commercial |
$1,849.95
|
| Rate for Payer: University Health Alliance Commercial |
$3,011.81
|
|
|
ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]
|
Facility
|
IP
|
$4,132.00
|
|
|
Service Code
|
HCPCS J9179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,512.20 |
| Max. Negotiated Rate |
$4,008.04 |
| Rate for Payer: Cash Price |
$2,479.20
|
| Rate for Payer: Cash Price |
$1,522.80
|
| Rate for Payer: Health Management Network Commercial |
$3,512.20
|
| Rate for Payer: Health Management Network Commercial |
$2,157.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,284.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,718.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,461.86
|
| Rate for Payer: MDX Hawaii PPO |
$4,008.04
|
|
|
ERTAPENEM 1 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080039]
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$215.05 |
| Max. Negotiated Rate |
$245.41 |
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Health Management Network Commercial |
$215.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$227.70
|
| Rate for Payer: MDX Hawaii PPO |
$245.41
|
|
|
ERTAPENEM 1 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080039]
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.71 |
| Max. Negotiated Rate |
$245.41 |
| Rate for Payer: AlohaCare Medicaid |
$126.50
|
| Rate for Payer: AlohaCare Medicare |
$78.43
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Cash Price |
$151.80
|
| Rate for Payer: Devoted Health Medicare |
$86.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.43
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$240.35
|
| Rate for Payer: Health Management Network Commercial |
$215.05
|
| Rate for Payer: Humana Medicare |
$78.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$227.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$129.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.43
|
| Rate for Payer: MDX Hawaii PPO |
$245.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$151.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.43
|
| Rate for Payer: University Health Alliance Commercial |
$184.41
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
|
|
ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: AlohaCare Medicaid |
$72.00
|
| Rate for Payer: AlohaCare Medicare |
$44.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Devoted Health Medicare |
$48.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Humana Medicare |
$44.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.64
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.64
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
|
|
ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL) [43031922]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
|
|
ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL) [43031922]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: AlohaCare Medicaid |
$72.00
|
| Rate for Payer: AlohaCare Medicaid |
$46.50
|
| Rate for Payer: AlohaCare Medicare |
$28.83
|
| Rate for Payer: AlohaCare Medicare |
$44.64
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Devoted Health Medicare |
$48.96
|
| Rate for Payer: Devoted Health Medicare |
$31.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.35
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Humana Medicare |
$44.64
|
| Rate for Payer: Humana Medicare |
$28.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.83
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.83
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
| Rate for Payer: University Health Alliance Commercial |
$67.79
|
|
|
ERYTHROMYCIN 0.5% OPHTH OINTMENT (1 GRAM) (TAKE HOME) [4080360]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080148
|
|
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
|
|
|
ERYTHROMYCIN 0.5% OPHTH OINTMENT (1 GRAM) (TAKE HOME) [4080360]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080148
|
|
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
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 24208091019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 72485067031
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$15.81
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$15.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.81
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 72485067031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.15 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00574402450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: AlohaCare Medicaid |
$29.50
|
| Rate for Payer: AlohaCare Medicare |
$18.29
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Devoted Health Medicare |
$20.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Humana Medicare |
$18.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.29
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.29
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00574402450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
