|
amino acids 4.25%-D10 (PPN) 1000 mL [HHSC]
|
Facility
|
IP
|
$192.71
|
|
|
Service Code
|
NDC 00338113403
|
| Hospital Charge Code |
2500043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$186.93 |
| Rate for Payer: Cash Price |
$125.26
|
| Rate for Payer: Health Management Network Commercial |
$163.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$173.44
|
| Rate for Payer: MDX Hawaii PPO |
$186.93
|
|
|
amino acids 5%-D20-elytes (TPN E) 1000 mL [HHSC]
|
Facility
|
OP
|
$289.53
|
|
|
Service Code
|
NDC 00338114803
|
| Hospital Charge Code |
2500874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.76 |
| Max. Negotiated Rate |
$280.84 |
| Rate for Payer: AlohaCare Medicaid |
$144.76
|
| Rate for Payer: AlohaCare Medicare |
$144.76
|
| Rate for Payer: Cash Price |
$188.19
|
| Rate for Payer: Devoted Health Medicare |
$159.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$144.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$275.05
|
| Rate for Payer: Health Management Network Commercial |
$246.10
|
| Rate for Payer: Humana Medicare |
$144.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$260.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$147.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$144.76
|
| Rate for Payer: MDX Hawaii PPO |
$280.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$144.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$144.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$173.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$144.76
|
| Rate for Payer: University Health Alliance Commercial |
$211.04
|
|
|
amino acids 5%-D20-elytes (TPN E) 1000 mL [HHSC]
|
Facility
|
IP
|
$289.53
|
|
|
Service Code
|
NDC 00338114803
|
| Hospital Charge Code |
2500874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$246.10 |
| Max. Negotiated Rate |
$280.84 |
| Rate for Payer: Cash Price |
$188.19
|
| Rate for Payer: Health Management Network Commercial |
$246.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$260.58
|
| Rate for Payer: MDX Hawaii PPO |
$280.84
|
|
|
amino acids 5%-D20 (TPN Plain) 1000 mL [HHSC]
|
Facility
|
OP
|
$287.76
|
|
|
Service Code
|
NDC 00338113803
|
| Hospital Charge Code |
2500984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.88 |
| Max. Negotiated Rate |
$279.13 |
| Rate for Payer: AlohaCare Medicaid |
$143.88
|
| Rate for Payer: AlohaCare Medicare |
$143.88
|
| Rate for Payer: Cash Price |
$187.04
|
| Rate for Payer: Devoted Health Medicare |
$158.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$143.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$273.37
|
| Rate for Payer: Health Management Network Commercial |
$244.60
|
| Rate for Payer: Humana Medicare |
$143.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$258.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$146.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$143.88
|
| Rate for Payer: MDX Hawaii PPO |
$279.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$143.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$143.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$172.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$143.88
|
| Rate for Payer: University Health Alliance Commercial |
$209.75
|
|
|
amino acids 5%-D20 (TPN Plain) 1000 mL [HHSC]
|
Facility
|
IP
|
$287.76
|
|
|
Service Code
|
NDC 00338113803
|
| Hospital Charge Code |
2500984
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.60 |
| Max. Negotiated Rate |
$279.13 |
| Rate for Payer: Cash Price |
$187.04
|
| Rate for Payer: Health Management Network Commercial |
$244.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$258.98
|
| Rate for Payer: MDX Hawaii PPO |
$279.13
|
|
|
amiodarone 150 mg/3mL vial [HHSC]
|
Facility
|
OP
|
$13.34
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
2500050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: AlohaCare Medicaid |
$6.67
|
| Rate for Payer: AlohaCare Medicaid |
$12.78
|
| Rate for Payer: AlohaCare Medicaid |
$8.34
|
| Rate for Payer: AlohaCare Medicare |
$8.34
|
| Rate for Payer: AlohaCare Medicare |
$6.67
|
| Rate for Payer: AlohaCare Medicare |
$12.78
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Devoted Health Medicare |
$7.34
|
| Rate for Payer: Devoted Health Medicare |
$14.06
|
| Rate for Payer: Devoted Health Medicare |
$9.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.28
|
| Rate for Payer: Health Management Network Commercial |
$21.73
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$14.18
|
| Rate for Payer: Humana Medicare |
$6.67
|
| Rate for Payer: Humana Medicare |
$8.34
|
| Rate for Payer: Humana Medicare |
$12.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.78
|
| Rate for Payer: MDX Hawaii PPO |
$24.79
|
| Rate for Payer: MDX Hawaii PPO |
$16.18
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.78
|
| Rate for Payer: University Health Alliance Commercial |
$9.72
|
| Rate for Payer: University Health Alliance Commercial |
$12.16
|
| Rate for Payer: University Health Alliance Commercial |
$18.63
|
|
|
amiodarone 150 mg/3mL vial [HHSC]
|
Facility
|
IP
|
$25.56
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
2500050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$24.79 |
| Rate for Payer: Cash Price |
$16.61
|
| Rate for Payer: Cash Price |
$10.84
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$21.73
|
| Rate for Payer: Health Management Network Commercial |
$14.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: MDX Hawaii PPO |
$16.18
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: MDX Hawaii PPO |
$24.79
|
|
|
amiodarone 200 mg tablet [HHSC]
|
Facility
|
IP
|
$3.37
|
|
|
Service Code
|
NDC 68084037101
|
| Hospital Charge Code |
2500048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.03
|
| Rate for Payer: MDX Hawaii PPO |
$3.27
|
|
|
amiodarone 200 mg tablet [HHSC]
|
Facility
|
IP
|
$3.37
|
|
|
Service Code
|
NDC 60687043701
|
| Hospital Charge Code |
2500048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.03
|
| Rate for Payer: MDX Hawaii PPO |
$3.27
|
|
|
amiodarone 200 mg tablet [HHSC]
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
NDC 60687043701
|
| Hospital Charge Code |
2500048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: AlohaCare Medicaid |
$1.69
|
| Rate for Payer: AlohaCare Medicare |
$1.69
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Devoted Health Medicare |
$1.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.20
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Humana Medicare |
$1.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.69
|
| Rate for Payer: MDX Hawaii PPO |
$3.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.69
|
| Rate for Payer: University Health Alliance Commercial |
$2.46
|
|
|
amiodarone 200 mg tablet [HHSC]
|
Facility
|
OP
|
$3.37
|
|
|
Service Code
|
NDC 68084037101
|
| Hospital Charge Code |
2500048
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$3.27 |
| Rate for Payer: AlohaCare Medicaid |
$1.69
|
| Rate for Payer: AlohaCare Medicare |
$1.69
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Devoted Health Medicare |
$1.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.20
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Humana Medicare |
$1.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.69
|
| Rate for Payer: MDX Hawaii PPO |
$3.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.69
|
| Rate for Payer: University Health Alliance Commercial |
$2.46
|
|
|
amiodarone-D5W 150 mg/100 mL premix [HHSC]
|
Facility
|
IP
|
$192.16
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2501116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$163.34 |
| Max. Negotiated Rate |
$186.40 |
| Rate for Payer: Cash Price |
$124.90
|
| Rate for Payer: Health Management Network Commercial |
$163.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.94
|
| Rate for Payer: MDX Hawaii PPO |
$186.40
|
|
|
amiodarone-D5W 150 mg/100 mL premix [HHSC]
|
Facility
|
OP
|
$192.16
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2501116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$186.40 |
| Rate for Payer: AlohaCare Medicaid |
$96.08
|
| Rate for Payer: AlohaCare Medicare |
$96.08
|
| Rate for Payer: Cash Price |
$124.90
|
| Rate for Payer: Cash Price |
$124.90
|
| Rate for Payer: Devoted Health Medicare |
$105.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$182.55
|
| Rate for Payer: Health Management Network Commercial |
$163.34
|
| Rate for Payer: Humana Medicare |
$96.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.08
|
| Rate for Payer: MDX Hawaii PPO |
$186.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$96.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$115.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.08
|
| Rate for Payer: University Health Alliance Commercial |
$140.07
|
|
|
amiodarone-D5W 360 mg/200 mL premix [HHSC]
|
Facility
|
OP
|
$293.11
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2500049
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$284.32 |
| Rate for Payer: AlohaCare Medicaid |
$146.56
|
| Rate for Payer: AlohaCare Medicare |
$146.56
|
| Rate for Payer: Cash Price |
$190.52
|
| Rate for Payer: Cash Price |
$190.52
|
| Rate for Payer: Devoted Health Medicare |
$161.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$146.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$278.45
|
| Rate for Payer: Health Management Network Commercial |
$249.14
|
| Rate for Payer: Humana Medicare |
$146.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$263.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$149.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$146.56
|
| Rate for Payer: MDX Hawaii PPO |
$284.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$146.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$146.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$175.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$146.56
|
| Rate for Payer: University Health Alliance Commercial |
$213.65
|
|
|
amiodarone-D5W 360 mg/200 mL premix [HHSC]
|
Facility
|
IP
|
$293.11
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
2500049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$249.14 |
| Max. Negotiated Rate |
$284.32 |
| Rate for Payer: Cash Price |
$190.52
|
| Rate for Payer: Health Management Network Commercial |
$249.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$263.80
|
| Rate for Payer: MDX Hawaii PPO |
$284.32
|
|
|
Amiodarone FSI
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
HCPCS 80151
|
| Hospital Charge Code |
8228835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$205.64 |
| Rate for Payer: AlohaCare Medicaid |
$106.00
|
| Rate for Payer: AlohaCare Medicare |
$106.00
|
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Devoted Health Medicare |
$116.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.64
|
| Rate for Payer: Health Management Network Commercial |
$180.20
|
| Rate for Payer: Humana Medicare |
$106.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$190.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$108.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.00
|
| Rate for Payer: MDX Hawaii PPO |
$205.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.00
|
| Rate for Payer: University Health Alliance Commercial |
$154.53
|
|
|
Amiodarone FSI
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
HCPCS 80151
|
| Hospital Charge Code |
8228835
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.20 |
| Max. Negotiated Rate |
$205.64 |
| Rate for Payer: Cash Price |
$137.80
|
| Rate for Payer: Health Management Network Commercial |
$180.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$190.80
|
| Rate for Payer: MDX Hawaii PPO |
$205.64
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$19.34
|
|
|
Service Code
|
NDC 50268008415
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$18.76 |
| Rate for Payer: Cash Price |
$12.57
|
| Rate for Payer: Health Management Network Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.41
|
| Rate for Payer: MDX Hawaii PPO |
$18.76
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$9.95
|
|
|
Service Code
|
NDC 67877019890
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.97 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: AlohaCare Medicaid |
$4.97
|
| Rate for Payer: AlohaCare Medicare |
$4.97
|
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Devoted Health Medicare |
$5.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.45
|
| Rate for Payer: Health Management Network Commercial |
$8.46
|
| Rate for Payer: Humana Medicare |
$4.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.97
|
| Rate for Payer: MDX Hawaii PPO |
$9.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.97
|
| Rate for Payer: University Health Alliance Commercial |
$7.25
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$19.34
|
|
|
Service Code
|
NDC 50268008415
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.67 |
| Max. Negotiated Rate |
$18.76 |
| Rate for Payer: AlohaCare Medicaid |
$9.67
|
| Rate for Payer: AlohaCare Medicare |
$9.67
|
| Rate for Payer: Cash Price |
$12.57
|
| Rate for Payer: Devoted Health Medicare |
$10.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.37
|
| Rate for Payer: Health Management Network Commercial |
$16.44
|
| Rate for Payer: Humana Medicare |
$9.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.67
|
| Rate for Payer: MDX Hawaii PPO |
$18.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.67
|
| Rate for Payer: University Health Alliance Commercial |
$14.10
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687048801
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$9.62
|
|
|
Service Code
|
NDC 51079045120
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: AlohaCare Medicaid |
$4.81
|
| Rate for Payer: AlohaCare Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Devoted Health Medicare |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.14
|
| Rate for Payer: Health Management Network Commercial |
$8.18
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.81
|
| Rate for Payer: MDX Hawaii PPO |
$9.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.81
|
| Rate for Payer: University Health Alliance Commercial |
$7.01
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687048801
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$9.62
|
|
|
Service Code
|
NDC 51079045120
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.18 |
| Max. Negotiated Rate |
$9.33 |
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Health Management Network Commercial |
$8.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.66
|
| Rate for Payer: MDX Hawaii PPO |
$9.33
|
|
|
amLODIPine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$9.95
|
|
|
Service Code
|
NDC 67877019890
|
| Hospital Charge Code |
2500052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Cash Price |
$6.47
|
| Rate for Payer: Health Management Network Commercial |
$8.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.96
|
| Rate for Payer: MDX Hawaii PPO |
$9.65
|
|
