|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [183757]
|
Facility
|
OP
|
$665.00
|
|
|
Service Code
|
HCPCS J0561
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.30 |
| Max. Negotiated Rate |
$645.05 |
| Rate for Payer: AlohaCare Medicaid |
$332.50
|
| Rate for Payer: AlohaCare Medicare |
$206.15
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Devoted Health Medicare |
$226.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$29.30
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$206.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$29.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$631.75
|
| Rate for Payer: Health Management Network Commercial |
$565.25
|
| Rate for Payer: Humana Medicare |
$206.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$598.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$339.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$206.15
|
| Rate for Payer: MDX Hawaii PPO |
$645.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$206.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$206.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$399.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$206.15
|
| Rate for Payer: University Health Alliance Commercial |
$484.72
|
|
|
PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE [183757]
|
Facility
|
IP
|
$665.00
|
|
|
Service Code
|
HCPCS J0561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$565.25 |
| Max. Negotiated Rate |
$645.05 |
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Health Management Network Commercial |
$565.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$598.50
|
| Rate for Payer: MDX Hawaii PPO |
$645.05
|
|
|
PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK [10900]
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
|
|
PENICILLIN G POTASSIUM 20,000,000 UNITS/40ML IJ (WET SOLR VIAL) [430608501]
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$142.59 |
| Rate for Payer: AlohaCare Medicaid |
$73.50
|
| Rate for Payer: AlohaCare Medicaid |
$61.50
|
| Rate for Payer: AlohaCare Medicare |
$38.13
|
| Rate for Payer: AlohaCare Medicare |
$45.57
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Devoted Health Medicare |
$41.82
|
| Rate for Payer: Devoted Health Medicare |
$49.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.57
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.65
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Humana Medicare |
$38.13
|
| Rate for Payer: Humana Medicare |
$45.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.57
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.13
|
| Rate for Payer: University Health Alliance Commercial |
$89.65
|
| Rate for Payer: University Health Alliance Commercial |
$107.15
|
|
|
PENICILLIN G POTASSIUM 20,000,000 UNITS/40ML IJ (WET SOLR VIAL) [430608501]
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$88.20
|
| Rate for Payer: Health Management Network Commercial |
$124.95
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$132.30
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: MDX Hawaii PPO |
$142.59
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: AlohaCare Medicaid |
$61.50
|
| Rate for Payer: AlohaCare Medicare |
$38.13
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Devoted Health Medicare |
$41.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.85
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Humana Medicare |
$38.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.13
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.13
|
| Rate for Payer: University Health Alliance Commercial |
$89.65
|
|
|
PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION [6085]
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$119.31 |
| Rate for Payer: Cash Price |
$73.80
|
| Rate for Payer: Health Management Network Commercial |
$104.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.70
|
| Rate for Payer: MDX Hawaii PPO |
$119.31
|
|
|
PENICILLIN G POTASSIUM 5,000,000 UNITS/5ML IJ (WET SOLR VIAL) [4306086]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicare |
$12.09
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: AlohaCare Medicare |
$7.13
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$10.54
|
| Rate for Payer: Devoted Health Medicare |
$7.82
|
| Rate for Payer: Devoted Health Medicare |
$13.26
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Humana Medicare |
$7.13
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.13
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.13
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
PENICILLIN G POTASSIUM 5,000,000 UNITS/5ML IJ (WET SOLR VIAL) [4306086]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT/100 ML NS ADD-A-VIAL (SIMPLE) [4080099]
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT/100 ML NS ADD-A-VIAL (SIMPLE) [4080099]
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicare |
$17.05
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Devoted Health Medicare |
$18.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.25
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Humana Medicare |
$17.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.05
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.05
|
| Rate for Payer: University Health Alliance Commercial |
$40.09
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicare |
$7.13
|
| Rate for Payer: AlohaCare Medicare |
$12.09
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Devoted Health Medicare |
$7.82
|
| Rate for Payer: Devoted Health Medicare |
$13.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Humana Medicare |
$7.13
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.09
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.13
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
|
|
PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6086]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J2540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION [6087]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
NDC 00781615395
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
|
|
PENICILLIN VK TABLETS (VEETIDS) 500 MG (TAKE HOME) [4080387]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080175
|
|
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
|
|
|
PENICILLIN VK TABLETS (VEETIDS) 500 MG (TAKE HOME) [4080387]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080175
|
|
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
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00093412773
|
|
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
|
|
|
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION [6091]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 00093412773
|
|
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
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00143983701
|
|
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
|
|
|
PENICILLIN V POTASSIUM 250 MG TABLET [6092]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00143983701
|
|
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
|
|
|
PENICILLIN V POTASSIUM 500 MG TABLET [6093]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 57237004101
|
|
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
|
|
|
PENICILLIN V POTASSIUM 500 MG TABLET [6093]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 57237004101
|
|
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
|
|
|
PENIS PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$24,958.21
|
|
|
Service Code
|
MSDRG 709
|
| Min. Negotiated Rate |
$24,958.21 |
| Max. Negotiated Rate |
$24,958.21 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,958.21
|
|
|
PENIS PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$24,958.21
|
|
|
Service Code
|
MSDRG 710
|
| Min. Negotiated Rate |
$24,958.21 |
| Max. Negotiated Rate |
$24,958.21 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,958.21
|
|
|
PENTAMIDINE 300 MG SOLUTION FOR INHALATION [28235]
|
Facility
|
IP
|
$271.00
|
|
|
Service Code
|
HCPCS J2545
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.35 |
| Max. Negotiated Rate |
$262.87 |
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Health Management Network Commercial |
$230.35
|
| Rate for Payer: Health Management Network Commercial |
$143.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.90
|
| Rate for Payer: MDX Hawaii PPO |
$262.87
|
| Rate for Payer: MDX Hawaii PPO |
$163.93
|
|
