|
AUTO SUTURE, TA 30, 3.5 MM RELOADS
|
Facility
|
IP
|
$202.00
|
|
| Hospital Charge Code |
8274221
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$131.30
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.80
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
AUTO SUTURE, TA 60 3.5 MM RELOADS
|
Facility
|
OP
|
$184.00
|
|
| Hospital Charge Code |
8274222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.00 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: AlohaCare Medicaid |
$92.00
|
| Rate for Payer: AlohaCare Medicare |
$92.00
|
| Rate for Payer: Cash Price |
$119.60
|
| Rate for Payer: Devoted Health Medicare |
$101.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$92.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.80
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: Humana Medicare |
$92.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$92.00
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$92.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$92.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$92.00
|
| Rate for Payer: University Health Alliance Commercial |
$134.12
|
|
|
AUTO SUTURE, TA 60 3.5 MM RELOADS
|
Facility
|
IP
|
$184.00
|
|
| Hospital Charge Code |
8274222
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$156.40 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Cash Price |
$119.60
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.60
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
|
|
AUTO SUTURE, TA 90 3.5 MM RELOADS
|
Facility
|
OP
|
$214.00
|
|
| Hospital Charge Code |
8274223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.00 |
| Max. Negotiated Rate |
$207.58 |
| Rate for Payer: AlohaCare Medicaid |
$107.00
|
| Rate for Payer: AlohaCare Medicare |
$107.00
|
| Rate for Payer: Cash Price |
$139.10
|
| Rate for Payer: Devoted Health Medicare |
$117.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$203.30
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Humana Medicare |
$107.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.00
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.00
|
| Rate for Payer: University Health Alliance Commercial |
$155.98
|
|
|
AUTO SUTURE, TA 90 3.5 MM RELOADS
|
Facility
|
IP
|
$214.00
|
|
| Hospital Charge Code |
8274223
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$181.90 |
| Max. Negotiated Rate |
$207.58 |
| Rate for Payer: Cash Price |
$139.10
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.60
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
|
|
azithromycin 200 mg/5 ml 30ml [HHSC]
|
Facility
|
IP
|
$163.95
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500087
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.36 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: Cash Price |
$106.57
|
| Rate for Payer: Health Management Network Commercial |
$139.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.56
|
| Rate for Payer: MDX Hawaii PPO |
$159.03
|
|
|
azithromycin 200 mg/5 ml 30ml [HHSC]
|
Facility
|
OP
|
$163.95
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500087
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.97 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: AlohaCare Medicaid |
$81.97
|
| Rate for Payer: AlohaCare Medicare |
$81.97
|
| Rate for Payer: Cash Price |
$106.57
|
| Rate for Payer: Devoted Health Medicare |
$90.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.75
|
| Rate for Payer: Health Management Network Commercial |
$139.36
|
| Rate for Payer: Humana Medicare |
$81.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.97
|
| Rate for Payer: MDX Hawaii PPO |
$159.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.97
|
| Rate for Payer: University Health Alliance Commercial |
$119.50
|
|
|
azithromycin 250 mg tablet [HHSC]
|
Facility
|
OP
|
$23.44
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.72 |
| Max. Negotiated Rate |
$22.74 |
| Rate for Payer: AlohaCare Medicaid |
$11.72
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicaid |
$5.21
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$11.72
|
| Rate for Payer: AlohaCare Medicare |
$5.21
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Devoted Health Medicare |
$12.89
|
| Rate for Payer: Devoted Health Medicare |
$5.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$19.92
|
| Rate for Payer: Health Management Network Commercial |
$8.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$5.21
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$11.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$10.10
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$22.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.21
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$7.59
|
| Rate for Payer: University Health Alliance Commercial |
$17.09
|
|
|
azithromycin 250 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500088
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$8.85
|
| Rate for Payer: Health Management Network Commercial |
$19.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$10.10
|
| Rate for Payer: MDX Hawaii PPO |
$22.74
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
azithromycin 500 mg vial [HHSC]
|
Facility
|
OP
|
$44.74
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
2500089
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicaid |
$26.56
|
| Rate for Payer: AlohaCare Medicaid |
$32.06
|
| Rate for Payer: AlohaCare Medicaid |
$9.77
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$26.56
|
| Rate for Payer: AlohaCare Medicare |
$32.06
|
| Rate for Payer: AlohaCare Medicare |
$9.77
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$10.74
|
| Rate for Payer: Devoted Health Medicare |
$29.22
|
| Rate for Payer: Devoted Health Medicare |
$35.27
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.92
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$16.60
|
| Rate for Payer: Health Management Network Commercial |
$54.51
|
| Rate for Payer: Health Management Network Commercial |
$45.15
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$9.77
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Humana Medicare |
$26.56
|
| Rate for Payer: Humana Medicare |
$32.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$32.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.06
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$51.53
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$18.94
|
| Rate for Payer: MDX Hawaii PPO |
$62.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: University Health Alliance Commercial |
$14.24
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$38.72
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
| Rate for Payer: University Health Alliance Commercial |
$46.74
|
|
|
azithromycin 500 mg vial [HHSC]
|
Facility
|
IP
|
$53.12
|
|
|
Service Code
|
HCPCS J0456
|
| Hospital Charge Code |
2500089
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.15 |
| Max. Negotiated Rate |
$51.53 |
| Rate for Payer: Cash Price |
$34.53
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$41.68
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$45.15
|
| Rate for Payer: Health Management Network Commercial |
$54.51
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$16.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.72
|
| Rate for Payer: MDX Hawaii PPO |
$51.53
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$18.94
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$62.21
|
|
|
aztreonam 2 g vial [HHSC]
|
Facility
|
OP
|
$380.01
|
|
|
Service Code
|
NDC 63323040230
|
| Hospital Charge Code |
2500091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$190.00 |
| Max. Negotiated Rate |
$368.61 |
| Rate for Payer: AlohaCare Medicaid |
$190.00
|
| Rate for Payer: AlohaCare Medicare |
$190.00
|
| Rate for Payer: Cash Price |
$247.01
|
| Rate for Payer: Devoted Health Medicare |
$209.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$190.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.01
|
| Rate for Payer: Health Management Network Commercial |
$323.01
|
| Rate for Payer: Humana Medicare |
$190.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$193.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$190.00
|
| Rate for Payer: MDX Hawaii PPO |
$368.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$190.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$190.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$228.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$190.00
|
| Rate for Payer: University Health Alliance Commercial |
$276.99
|
|
|
aztreonam 2 g vial [HHSC]
|
Facility
|
OP
|
$406.57
|
|
|
Service Code
|
NDC 63323040220
|
| Hospital Charge Code |
2500091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.28 |
| Max. Negotiated Rate |
$394.37 |
| Rate for Payer: AlohaCare Medicaid |
$203.28
|
| Rate for Payer: AlohaCare Medicare |
$203.28
|
| Rate for Payer: Cash Price |
$264.27
|
| Rate for Payer: Devoted Health Medicare |
$223.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$203.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$386.24
|
| Rate for Payer: Health Management Network Commercial |
$345.58
|
| Rate for Payer: Humana Medicare |
$203.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$365.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$207.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$203.28
|
| Rate for Payer: MDX Hawaii PPO |
$394.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$203.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$203.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$243.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$203.28
|
| Rate for Payer: University Health Alliance Commercial |
$296.35
|
|
|
aztreonam 2 g vial [HHSC]
|
Facility
|
OP
|
$342.64
|
|
|
Service Code
|
NDC 00003257016
|
| Hospital Charge Code |
2500091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.32 |
| Max. Negotiated Rate |
$332.36 |
| Rate for Payer: AlohaCare Medicaid |
$171.32
|
| Rate for Payer: AlohaCare Medicare |
$171.32
|
| Rate for Payer: Cash Price |
$222.72
|
| Rate for Payer: Devoted Health Medicare |
$188.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$171.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$325.51
|
| Rate for Payer: Health Management Network Commercial |
$291.24
|
| Rate for Payer: Humana Medicare |
$171.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$308.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$174.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$171.32
|
| Rate for Payer: MDX Hawaii PPO |
$332.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$171.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$171.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$205.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$171.32
|
| Rate for Payer: University Health Alliance Commercial |
$249.75
|
|
|
aztreonam 2 g vial [HHSC]
|
Facility
|
IP
|
$342.64
|
|
|
Service Code
|
NDC 00003257016
|
| Hospital Charge Code |
2500091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$291.24 |
| Max. Negotiated Rate |
$332.36 |
| Rate for Payer: Cash Price |
$222.72
|
| Rate for Payer: Health Management Network Commercial |
$291.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$308.38
|
| Rate for Payer: MDX Hawaii PPO |
$332.36
|
|
|
aztreonam 2 g vial [HHSC]
|
Facility
|
IP
|
$406.57
|
|
|
Service Code
|
NDC 63323040220
|
| Hospital Charge Code |
2500091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$345.58 |
| Max. Negotiated Rate |
$394.37 |
| Rate for Payer: Cash Price |
$264.27
|
| Rate for Payer: Health Management Network Commercial |
$345.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$365.91
|
| Rate for Payer: MDX Hawaii PPO |
$394.37
|
|
|
aztreonam 2 g vial [HHSC]
|
Facility
|
IP
|
$380.01
|
|
|
Service Code
|
NDC 63323040230
|
| Hospital Charge Code |
2500091
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.01 |
| Max. Negotiated Rate |
$368.61 |
| Rate for Payer: Cash Price |
$247.01
|
| Rate for Payer: Health Management Network Commercial |
$323.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.01
|
| Rate for Payer: MDX Hawaii PPO |
$368.61
|
|
|
bacitracin 500 units/gm oint 14gm [HHSC]
|
Facility
|
OP
|
$20.02
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500093
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$19.42 |
| Rate for Payer: AlohaCare Medicaid |
$10.01
|
| Rate for Payer: AlohaCare Medicare |
$10.01
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Devoted Health Medicare |
$11.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.02
|
| Rate for Payer: Health Management Network Commercial |
$17.02
|
| Rate for Payer: Humana Medicare |
$10.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.01
|
| Rate for Payer: MDX Hawaii PPO |
$19.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.01
|
| Rate for Payer: University Health Alliance Commercial |
$14.59
|
|
|
bacitracin 500 units/gm oint 14gm [HHSC]
|
Facility
|
IP
|
$20.02
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500093
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$19.42 |
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Health Management Network Commercial |
$17.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.02
|
| Rate for Payer: MDX Hawaii PPO |
$19.42
|
|
|
bacitracin-polymyx 3.5gm ointment [HHSC]
|
Facility
|
OP
|
$46.02
|
|
|
Service Code
|
NDC 00574402135
|
| Hospital Charge Code |
2500096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.01 |
| Max. Negotiated Rate |
$44.64 |
| Rate for Payer: AlohaCare Medicaid |
$23.01
|
| Rate for Payer: AlohaCare Medicare |
$23.01
|
| Rate for Payer: Cash Price |
$29.91
|
| Rate for Payer: Devoted Health Medicare |
$25.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.72
|
| Rate for Payer: Health Management Network Commercial |
$39.12
|
| Rate for Payer: Humana Medicare |
$23.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.01
|
| Rate for Payer: MDX Hawaii PPO |
$44.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.01
|
| Rate for Payer: University Health Alliance Commercial |
$33.54
|
|
|
bacitracin-polymyx 3.5gm ointment [HHSC]
|
Facility
|
IP
|
$46.02
|
|
|
Service Code
|
NDC 00574402135
|
| Hospital Charge Code |
2500096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.12 |
| Max. Negotiated Rate |
$44.64 |
| Rate for Payer: Cash Price |
$29.91
|
| Rate for Payer: Health Management Network Commercial |
$39.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.42
|
| Rate for Payer: MDX Hawaii PPO |
$44.64
|
|
|
bacitracin-polymyx 3.5gm ointment [HHSC]
|
Facility
|
OP
|
$49.54
|
|
|
Service Code
|
NDC 24208055555
|
| Hospital Charge Code |
2500096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.77 |
| Max. Negotiated Rate |
$48.05 |
| Rate for Payer: AlohaCare Medicaid |
$24.77
|
| Rate for Payer: AlohaCare Medicare |
$24.77
|
| Rate for Payer: Cash Price |
$32.20
|
| Rate for Payer: Devoted Health Medicare |
$27.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.06
|
| Rate for Payer: Health Management Network Commercial |
$42.11
|
| Rate for Payer: Humana Medicare |
$24.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.77
|
| Rate for Payer: MDX Hawaii PPO |
$48.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.77
|
| Rate for Payer: University Health Alliance Commercial |
$36.11
|
|
|
bacitracin-polymyx 3.5gm ointment [HHSC]
|
Facility
|
IP
|
$49.54
|
|
|
Service Code
|
NDC 24208055555
|
| Hospital Charge Code |
2500096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.11 |
| Max. Negotiated Rate |
$48.05 |
| Rate for Payer: Cash Price |
$32.20
|
| Rate for Payer: Health Management Network Commercial |
$42.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.59
|
| Rate for Payer: MDX Hawaii PPO |
$48.05
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC
|
Facility
|
IP
|
$49,870.18
|
|
|
Service Code
|
MSDRG 519
|
| Min. Negotiated Rate |
$49,870.18 |
| Max. Negotiated Rate |
$49,870.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$49,870.18
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR
|
Facility
|
IP
|
$49,870.18
|
|
|
Service Code
|
MSDRG 518
|
| Min. Negotiated Rate |
$49,870.18 |
| Max. Negotiated Rate |
$49,870.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$49,870.18
|
|
