|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$13.02
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$13.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.02
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION [472]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
AMPICILLIN 500 MG CAPSULE [466]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00781214501
|
|
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
|
|
|
AMPICILLIN 500 MG CAPSULE [466]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00781214501
|
|
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
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| 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: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| 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 Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION [474]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS J0290
|
|
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
|
|
|
AMPICILLIN SODIUM 1 G/8ML IJ (WET SOLR VIAL) [430469]
|
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: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
AMPICILLIN SODIUM 1 G/8ML IJ (WET SOLR VIAL) [430469]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$8.06
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| 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 Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Humana Medicare |
$8.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.06
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.06
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
AMPICILLIN SODIUM 2 G/16ML IJ (WET SOLR VIAL) [430472]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
AMPICILLIN SODIUM 2 G/16ML IJ (WET SOLR VIAL) [430472]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$13.02
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$13.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.02
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
AMPICILLIN SODIUM 500 MG/2ML IJ (WET SOLR VIAL) [430474]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| 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: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| 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 Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
AMPICILLIN SODIUM 500 MG/2ML IJ (WET SOLR VIAL) [430474]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS J0290
|
|
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
|
|
|
AMPICILLIN SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [43047401]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| 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: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| 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 Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
AMPICILLIN SODIUM 500 MG/5ML IJ (WET SOLR VIAL) [43047401]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS J0290
|
|
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
|
|
|
AMPICILLIN-SULBACTAM 1.5 G/4ML IJ (WET SOLR VIAL) [4309083]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
AMPICILLIN-SULBACTAM 1.5 G/4ML IJ (WET SOLR VIAL) [4309083]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION [9083]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
AMPICILLIN-SULBACTAM 3 G/8ML IJ (WET SOLR VIAL) [4309084]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
AMPICILLIN-SULBACTAM 3 G/8ML IJ (WET SOLR VIAL) [4309084]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION [9084]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
AMPICILLIN-SULBACTAM IVPB 3 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080112]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$13.02
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$13.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.02
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
AMPICILLIN-SULBACTAM IVPB 3 G IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080112]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
AMPLATZ SHORT TAPER EX 035X260
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$72.54 |
| Max. Negotiated Rate |
$226.98 |
| Rate for Payer: AlohaCare Medicaid |
$117.00
|
| Rate for Payer: AlohaCare Medicare |
$72.54
|
| Rate for Payer: Cash Price |
$140.40
|
| Rate for Payer: Devoted Health Medicare |
$79.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$72.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$222.30
|
| Rate for Payer: Health Management Network Commercial |
$198.90
|
| Rate for Payer: Humana Medicare |
$72.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$210.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$119.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$72.54
|
| Rate for Payer: MDX Hawaii PPO |
$226.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$72.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$72.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$72.54
|
| Rate for Payer: University Health Alliance Commercial |
$170.56
|
|
