|
donepezil 5 mg tablet [HHSC]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 60687029201
|
| Hospital Charge Code |
2500271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: AlohaCare Medicaid |
$2.16
|
| Rate for Payer: AlohaCare Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.10
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Humana Medicare |
$2.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.16
|
| Rate for Payer: University Health Alliance Commercial |
$3.15
|
|
|
DOPamine 200 mg/5 mL vial [HHSC]
|
Facility
|
OP
|
$19.47
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2501067
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$18.89 |
| Rate for Payer: AlohaCare Medicaid |
$9.73
|
| Rate for Payer: AlohaCare Medicaid |
$9.76
|
| Rate for Payer: AlohaCare Medicare |
$9.76
|
| Rate for Payer: AlohaCare Medicare |
$9.73
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Devoted Health Medicare |
$10.71
|
| Rate for Payer: Devoted Health Medicare |
$10.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.54
|
| Rate for Payer: Health Management Network Commercial |
$16.59
|
| Rate for Payer: Health Management Network Commercial |
$16.55
|
| Rate for Payer: Humana Medicare |
$9.73
|
| Rate for Payer: Humana Medicare |
$9.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.76
|
| Rate for Payer: MDX Hawaii PPO |
$18.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.76
|
| Rate for Payer: University Health Alliance Commercial |
$14.19
|
| Rate for Payer: University Health Alliance Commercial |
$14.23
|
|
|
DOPamine 200 mg/5 mL vial [HHSC]
|
Facility
|
IP
|
$19.47
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2501067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.55 |
| Max. Negotiated Rate |
$18.89 |
| Rate for Payer: Cash Price |
$12.66
|
| Rate for Payer: Cash Price |
$12.69
|
| Rate for Payer: Health Management Network Commercial |
$16.55
|
| Rate for Payer: Health Management Network Commercial |
$16.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.57
|
| Rate for Payer: MDX Hawaii PPO |
$18.93
|
| Rate for Payer: MDX Hawaii PPO |
$18.89
|
|
|
DOPamine 400 mg/10ml vial [HHSC]
|
Facility
|
OP
|
$11.48
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2500273
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: AlohaCare Medicaid |
$5.74
|
| Rate for Payer: AlohaCare Medicaid |
$21.94
|
| Rate for Payer: AlohaCare Medicare |
$21.94
|
| Rate for Payer: AlohaCare Medicare |
$5.74
|
| Rate for Payer: Cash Price |
$28.52
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cash Price |
$28.52
|
| Rate for Payer: Devoted Health Medicare |
$6.31
|
| Rate for Payer: Devoted Health Medicare |
$24.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.69
|
| Rate for Payer: Health Management Network Commercial |
$37.30
|
| Rate for Payer: Health Management Network Commercial |
$9.76
|
| Rate for Payer: Humana Medicare |
$5.74
|
| Rate for Payer: Humana Medicare |
$21.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.94
|
| Rate for Payer: MDX Hawaii PPO |
$11.14
|
| Rate for Payer: MDX Hawaii PPO |
$42.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.94
|
| Rate for Payer: University Health Alliance Commercial |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$31.98
|
|
|
DOPamine 400 mg/10ml vial [HHSC]
|
Facility
|
IP
|
$11.48
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2500273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.76 |
| Max. Negotiated Rate |
$11.14 |
| Rate for Payer: Cash Price |
$7.46
|
| Rate for Payer: Cash Price |
$28.52
|
| Rate for Payer: Health Management Network Commercial |
$9.76
|
| Rate for Payer: Health Management Network Commercial |
$37.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.49
|
| Rate for Payer: MDX Hawaii PPO |
$42.56
|
| Rate for Payer: MDX Hawaii PPO |
$11.14
|
|
|
DOPamine-D5W 400 mg/250 ml premix [HHSC]
|
Facility
|
IP
|
$79.24
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2500272
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.35 |
| Max. Negotiated Rate |
$76.86 |
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Health Management Network Commercial |
$67.35
|
| Rate for Payer: Health Management Network Commercial |
$82.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.94
|
| Rate for Payer: MDX Hawaii PPO |
$93.70
|
| Rate for Payer: MDX Hawaii PPO |
$76.86
|
|
|
DOPamine-D5W 400 mg/250 ml premix [HHSC]
|
Facility
|
OP
|
$79.24
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
2500272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$76.86 |
| Rate for Payer: AlohaCare Medicaid |
$39.62
|
| Rate for Payer: AlohaCare Medicaid |
$48.30
|
| Rate for Payer: AlohaCare Medicare |
$48.30
|
| Rate for Payer: AlohaCare Medicare |
$39.62
|
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Cash Price |
$62.79
|
| Rate for Payer: Devoted Health Medicare |
$43.58
|
| Rate for Payer: Devoted Health Medicare |
$53.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.77
|
| Rate for Payer: Health Management Network Commercial |
$82.11
|
| Rate for Payer: Health Management Network Commercial |
$67.35
|
| Rate for Payer: Humana Medicare |
$48.30
|
| Rate for Payer: Humana Medicare |
$39.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.30
|
| Rate for Payer: MDX Hawaii PPO |
$76.86
|
| Rate for Payer: MDX Hawaii PPO |
$93.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.30
|
| Rate for Payer: University Health Alliance Commercial |
$57.76
|
| Rate for Payer: University Health Alliance Commercial |
$70.41
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, NARROW, LEFT, 4H
|
Facility
|
IP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.20 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, NARROW, LEFT, 4H
|
Facility
|
OP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987338
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.00 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,360.00
|
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Humana Medicare |
$1,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,387.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, LEFT, 4H
|
Facility
|
OP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.00 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,360.00
|
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Humana Medicare |
$1,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,387.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, LEFT, 4H
|
Facility
|
IP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12987336
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.20 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, RIGHT, 4H
|
Facility
|
OP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,360.00 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,360.00
|
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Humana Medicare |
$1,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,387.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,360.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
DORSAL DISTAL RADIUS PLATE, TI, STANDARD, RIGHT, 4H
|
Facility
|
IP
|
$2,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12985758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,523.20 |
| Max. Negotiated Rate |
$2,638.40 |
| Rate for Payer: Cash Price |
$1,768.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,904.00
|
| Rate for Payer: Health Management Network Commercial |
$2,312.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,448.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,638.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,523.20
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
IP
|
$39.62
|
|
|
Service Code
|
NDC 27808023401
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: Cash Price |
$25.75
|
| Rate for Payer: Health Management Network Commercial |
$33.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.66
|
| Rate for Payer: MDX Hawaii PPO |
$38.43
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
IP
|
$39.62
|
|
|
Service Code
|
NDC 72578000118
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: Cash Price |
$25.75
|
| Rate for Payer: Health Management Network Commercial |
$33.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.66
|
| Rate for Payer: MDX Hawaii PPO |
$38.43
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
IP
|
$31.07
|
|
|
Service Code
|
NDC 62584069321
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.41 |
| Max. Negotiated Rate |
$30.14 |
| Rate for Payer: Cash Price |
$20.20
|
| Rate for Payer: Health Management Network Commercial |
$26.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.96
|
| Rate for Payer: MDX Hawaii PPO |
$30.14
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
OP
|
$39.62
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.81 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: AlohaCare Medicaid |
$19.81
|
| Rate for Payer: AlohaCare Medicare |
$19.81
|
| Rate for Payer: Cash Price |
$25.75
|
| Rate for Payer: Devoted Health Medicare |
$21.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.64
|
| Rate for Payer: Health Management Network Commercial |
$33.68
|
| Rate for Payer: Humana Medicare |
$19.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.81
|
| Rate for Payer: MDX Hawaii PPO |
$38.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.81
|
| Rate for Payer: University Health Alliance Commercial |
$28.88
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
IP
|
$39.62
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.68 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: Cash Price |
$25.75
|
| Rate for Payer: Health Management Network Commercial |
$33.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.66
|
| Rate for Payer: MDX Hawaii PPO |
$38.43
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
OP
|
$29.72
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.86 |
| Max. Negotiated Rate |
$28.83 |
| Rate for Payer: AlohaCare Medicaid |
$14.86
|
| Rate for Payer: AlohaCare Medicare |
$14.86
|
| Rate for Payer: Cash Price |
$19.32
|
| Rate for Payer: Devoted Health Medicare |
$16.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.23
|
| Rate for Payer: Health Management Network Commercial |
$25.26
|
| Rate for Payer: Humana Medicare |
$14.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.86
|
| Rate for Payer: MDX Hawaii PPO |
$28.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.86
|
| Rate for Payer: University Health Alliance Commercial |
$21.66
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
IP
|
$29.72
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.26 |
| Max. Negotiated Rate |
$28.83 |
| Rate for Payer: Cash Price |
$19.32
|
| Rate for Payer: Health Management Network Commercial |
$25.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.75
|
| Rate for Payer: MDX Hawaii PPO |
$28.83
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
OP
|
$39.62
|
|
|
Service Code
|
NDC 27808023401
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.81 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: AlohaCare Medicaid |
$19.81
|
| Rate for Payer: AlohaCare Medicare |
$19.81
|
| Rate for Payer: Cash Price |
$25.75
|
| Rate for Payer: Devoted Health Medicare |
$21.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.64
|
| Rate for Payer: Health Management Network Commercial |
$33.68
|
| Rate for Payer: Humana Medicare |
$19.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.81
|
| Rate for Payer: MDX Hawaii PPO |
$38.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.81
|
| Rate for Payer: University Health Alliance Commercial |
$28.88
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
OP
|
$39.62
|
|
|
Service Code
|
NDC 72578000118
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.81 |
| Max. Negotiated Rate |
$38.43 |
| Rate for Payer: AlohaCare Medicaid |
$19.81
|
| Rate for Payer: AlohaCare Medicare |
$19.81
|
| Rate for Payer: Cash Price |
$25.75
|
| Rate for Payer: Devoted Health Medicare |
$21.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.64
|
| Rate for Payer: Health Management Network Commercial |
$33.68
|
| Rate for Payer: Humana Medicare |
$19.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.81
|
| Rate for Payer: MDX Hawaii PPO |
$38.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.81
|
| Rate for Payer: University Health Alliance Commercial |
$28.88
|
|
|
doxycycline 100 mg tablet [HHSC]
|
Facility
|
OP
|
$31.07
|
|
|
Service Code
|
NDC 62584069321
|
| Hospital Charge Code |
2500277
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$30.14 |
| Rate for Payer: AlohaCare Medicaid |
$15.54
|
| Rate for Payer: AlohaCare Medicare |
$15.54
|
| Rate for Payer: Cash Price |
$20.20
|
| Rate for Payer: Devoted Health Medicare |
$17.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.52
|
| Rate for Payer: Health Management Network Commercial |
$26.41
|
| Rate for Payer: Humana Medicare |
$15.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.54
|
| Rate for Payer: MDX Hawaii PPO |
$30.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.54
|
| Rate for Payer: University Health Alliance Commercial |
$22.65
|
|
|
doxycycline 100 mg vial [HHSC]
|
Facility
|
OP
|
$139.34
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
2500276
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$135.16 |
| Rate for Payer: AlohaCare Medicaid |
$69.67
|
| Rate for Payer: AlohaCare Medicaid |
$47.12
|
| Rate for Payer: AlohaCare Medicaid |
$72.19
|
| Rate for Payer: AlohaCare Medicare |
$72.19
|
| Rate for Payer: AlohaCare Medicare |
$69.67
|
| Rate for Payer: AlohaCare Medicare |
$47.12
|
| Rate for Payer: Cash Price |
$93.85
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cash Price |
$93.85
|
| Rate for Payer: Cash Price |
$90.57
|
| Rate for Payer: Cash Price |
$90.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Devoted Health Medicare |
$76.64
|
| Rate for Payer: Devoted Health Medicare |
$51.83
|
| Rate for Payer: Devoted Health Medicare |
$79.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$72.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$132.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$89.53
|
| Rate for Payer: Health Management Network Commercial |
$80.10
|
| Rate for Payer: Health Management Network Commercial |
$118.44
|
| Rate for Payer: Health Management Network Commercial |
$122.73
|
| Rate for Payer: Humana Medicare |
$69.67
|
| Rate for Payer: Humana Medicare |
$72.19
|
| Rate for Payer: Humana Medicare |
$47.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$72.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.12
|
| Rate for Payer: MDX Hawaii PPO |
$91.41
|
| Rate for Payer: MDX Hawaii PPO |
$140.06
|
| Rate for Payer: MDX Hawaii PPO |
$135.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$72.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$72.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$83.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$72.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.12
|
| Rate for Payer: University Health Alliance Commercial |
$101.56
|
| Rate for Payer: University Health Alliance Commercial |
$105.25
|
| Rate for Payer: University Health Alliance Commercial |
$68.69
|
|
|
doxycycline 100 mg vial [HHSC]
|
Facility
|
IP
|
$94.24
|
|
|
Service Code
|
HCPCS J1271
|
| Hospital Charge Code |
2500276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.10 |
| Max. Negotiated Rate |
$91.41 |
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cash Price |
$93.85
|
| Rate for Payer: Cash Price |
$90.57
|
| Rate for Payer: Health Management Network Commercial |
$118.44
|
| Rate for Payer: Health Management Network Commercial |
$80.10
|
| Rate for Payer: Health Management Network Commercial |
$122.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.41
|
| Rate for Payer: MDX Hawaii PPO |
$140.06
|
| Rate for Payer: MDX Hawaii PPO |
$135.16
|
| Rate for Payer: MDX Hawaii PPO |
$91.41
|
|
