|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 60687080311
|
|
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
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 65862050320
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET [33228]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 60687080301
|
|
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
|
|
|
AMOXICILLIN CAPSULES (AMOXIL) 500 MG (TAKE HOME) [4080335]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080123
|
|
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
|
|
|
AMOXICILLIN CAPSULES (AMOXIL) 500 MG (TAKE HOME) [4080335]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080123
|
|
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
|
|
|
AMOXICILLIN/CLAVULANATE 875/125 MG TABLETS (AUGMENTIN) (TAKE HOME) [4080336]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080124
|
|
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
|
|
|
AMOXICILLIN/CLAVULANATE 875/125 MG TABLETS (AUGMENTIN) (TAKE HOME) [4080336]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080124
|
|
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
|
|
|
AMOXICILLIN/CLAVULANATE SUSPENSION (AUGMENTIN) 400 MG/5 ML (100 ML) (TAKE HOME) [4080337]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080125
|
|
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
|
|
|
AMOXICILLIN/CLAVULANATE SUSPENSION (AUGMENTIN) 400 MG/5 ML (100 ML) (TAKE HOME) [4080337]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080125
|
|
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
|
|
|
AMOXICILLIN SUSPENSION 125 MG/5 ML (150 ML) (TAKE HOME) [4080333]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080121
|
|
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
|
|
|
AMOXICILLIN SUSPENSION 125 MG/5 ML (150 ML) (TAKE HOME) [4080333]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080121
|
|
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
|
|
|
AMOXICILLIN SUSPENSION 400 MG/5 ML (100 ML) (TAKE HOME) [4080334]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080122
|
|
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
|
|
|
AMOXICILLIN SUSPENSION 400 MG/5 ML (100 ML) (TAKE HOME) [4080334]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080122
|
|
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
|
|
|
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [166800]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS J0285
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
|
AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION [166800]
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS J0285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$37.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Devoted Health Medicare |
$40.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$34.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$34.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$37.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.20
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$72.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.20
|
| Rate for Payer: University Health Alliance Commercial |
$87.47
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV (WET SUSR VIAL) [43021900]
|
Facility
|
IP
|
$1,479.00
|
|
|
Service Code
|
HCPCS J0289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,257.15 |
| Max. Negotiated Rate |
$1,434.63 |
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Health Management Network Commercial |
$487.05
|
| Rate for Payer: Health Management Network Commercial |
$1,257.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,331.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$515.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,434.63
|
| Rate for Payer: MDX Hawaii PPO |
$555.81
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG/12.5ML IV (WET SUSR VIAL) [43021900]
|
Facility
|
OP
|
$1,479.00
|
|
|
Service Code
|
HCPCS J0289
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$1,434.63 |
| Rate for Payer: AlohaCare Medicaid |
$739.50
|
| Rate for Payer: AlohaCare Medicaid |
$286.50
|
| Rate for Payer: AlohaCare Medicare |
$177.63
|
| Rate for Payer: AlohaCare Medicare |
$458.49
|
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cash Price |
$887.40
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Devoted Health Medicare |
$502.86
|
| Rate for Payer: Devoted Health Medicare |
$194.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$458.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$177.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,405.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$544.35
|
| Rate for Payer: Health Management Network Commercial |
$1,257.15
|
| Rate for Payer: Health Management Network Commercial |
$487.05
|
| Rate for Payer: Humana Medicare |
$458.49
|
| Rate for Payer: Humana Medicare |
$177.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,331.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$515.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$754.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$292.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$458.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$177.63
|
| Rate for Payer: MDX Hawaii PPO |
$1,434.63
|
| Rate for Payer: MDX Hawaii PPO |
$555.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$177.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$458.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$458.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$177.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$887.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$343.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$177.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$458.49
|
| Rate for Payer: University Health Alliance Commercial |
$1,078.04
|
| Rate for Payer: University Health Alliance Commercial |
$417.66
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
IP
|
$573.00
|
|
|
Service Code
|
HCPCS J0289
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$487.05 |
| Max. Negotiated Rate |
$555.81 |
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Health Management Network Commercial |
$487.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$515.70
|
| Rate for Payer: MDX Hawaii PPO |
$555.81
|
|
|
AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION [21900]
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
HCPCS J0289
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$555.81 |
| Rate for Payer: AlohaCare Medicaid |
$286.50
|
| Rate for Payer: AlohaCare Medicare |
$177.63
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Devoted Health Medicare |
$194.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.62
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$177.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$544.35
|
| Rate for Payer: Health Management Network Commercial |
$487.05
|
| Rate for Payer: Humana Medicare |
$177.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$515.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$292.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$177.63
|
| Rate for Payer: MDX Hawaii PPO |
$555.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$177.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$177.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$343.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$177.63
|
| Rate for Payer: University Health Alliance Commercial |
$417.66
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION [469]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$8.06
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$8.06
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.06
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
AMPICILLIN 250 MG SOLUTION FOR INJECTION [473]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| 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: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| 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 Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
AMPICILLIN 250 MG SOLUTION FOR INJECTION [473]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J0290
|
|
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
|
|
|
AMPICILLIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080102]
|
Facility
|
IP
|
$4,264.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,624.40 |
| Max. Negotiated Rate |
$4,136.08 |
| Rate for Payer: Cash Price |
$2,558.40
|
| Rate for Payer: Health Management Network Commercial |
$3,624.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,837.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,136.08
|
|
|
AMPICILLIN 2 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080102]
|
Facility
|
OP
|
$4,264.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$4,136.08 |
| Rate for Payer: AlohaCare Medicaid |
$2,132.00
|
| Rate for Payer: AlohaCare Medicare |
$1,321.84
|
| Rate for Payer: Cash Price |
$2,558.40
|
| Rate for Payer: Cash Price |
$2,558.40
|
| Rate for Payer: Devoted Health Medicare |
$1,449.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,321.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,050.80
|
| Rate for Payer: Health Management Network Commercial |
$3,624.40
|
| Rate for Payer: Humana Medicare |
$1,321.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,837.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,174.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,321.84
|
| Rate for Payer: MDX Hawaii PPO |
$4,136.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,321.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,321.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,558.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,321.84
|
| Rate for Payer: University Health Alliance Commercial |
$3,108.03
|
|
