|
povidone iodine 10% topical 118 mL [HHSC]
|
Facility
|
IP
|
$10.39
|
|
|
Service Code
|
NDC 67618015004
|
| Hospital Charge Code |
2501041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.83 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Health Management Network Commercial |
$8.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.35
|
| Rate for Payer: MDX Hawaii PPO |
$10.08
|
|
|
povidone iodine 10% topical 118 mL [HHSC]
|
Facility
|
OP
|
$10.39
|
|
|
Service Code
|
NDC 67618015004
|
| Hospital Charge Code |
2501041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$10.08 |
| Rate for Payer: AlohaCare Medicaid |
$5.20
|
| Rate for Payer: AlohaCare Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Devoted Health Medicare |
$5.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.87
|
| Rate for Payer: Health Management Network Commercial |
$8.83
|
| Rate for Payer: Humana Medicare |
$5.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.20
|
| Rate for Payer: MDX Hawaii PPO |
$10.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.20
|
| Rate for Payer: University Health Alliance Commercial |
$7.57
|
|
|
povidone iodine 10% topical 473ml [HHSC]
|
Facility
|
OP
|
$25.38
|
|
|
Service Code
|
NDC 67618015017
|
| Hospital Charge Code |
2500685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.69 |
| Max. Negotiated Rate |
$24.62 |
| Rate for Payer: AlohaCare Medicaid |
$12.69
|
| Rate for Payer: AlohaCare Medicare |
$12.69
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Devoted Health Medicare |
$13.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.11
|
| Rate for Payer: Health Management Network Commercial |
$21.57
|
| Rate for Payer: Humana Medicare |
$12.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.69
|
| Rate for Payer: MDX Hawaii PPO |
$24.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.69
|
| Rate for Payer: University Health Alliance Commercial |
$18.50
|
|
|
povidone iodine 10% topical 473ml [HHSC]
|
Facility
|
IP
|
$25.38
|
|
|
Service Code
|
NDC 67618015017
|
| Hospital Charge Code |
2500685
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.57 |
| Max. Negotiated Rate |
$24.62 |
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Health Management Network Commercial |
$21.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.84
|
| Rate for Payer: MDX Hawaii PPO |
$24.62
|
|
|
povidone iodine 5% ophth soln 5ml [HHSC]
|
Facility
|
OP
|
$13.16
|
|
|
Service Code
|
NDC 00065041130
|
| Hospital Charge Code |
2500684
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.58 |
| Max. Negotiated Rate |
$12.77 |
| Rate for Payer: AlohaCare Medicaid |
$6.58
|
| Rate for Payer: AlohaCare Medicare |
$6.58
|
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: Devoted Health Medicare |
$7.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.50
|
| Rate for Payer: Health Management Network Commercial |
$11.19
|
| Rate for Payer: Humana Medicare |
$6.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.58
|
| Rate for Payer: MDX Hawaii PPO |
$12.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.58
|
| Rate for Payer: University Health Alliance Commercial |
$9.59
|
|
|
povidone iodine 5% ophth soln 5ml [HHSC]
|
Facility
|
IP
|
$13.16
|
|
|
Service Code
|
NDC 00065041130
|
| Hospital Charge Code |
2500684
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$12.77 |
| Rate for Payer: Cash Price |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$11.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.84
|
| Rate for Payer: MDX Hawaii PPO |
$12.77
|
|
|
PP acetaminoph 120 mg supp #4 [HHSC]
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530909
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$12.56 |
| Rate for Payer: AlohaCare Medicaid |
$6.47
|
| Rate for Payer: AlohaCare Medicare |
$6.47
|
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Devoted Health Medicare |
$7.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.30
|
| Rate for Payer: Health Management Network Commercial |
$11.01
|
| Rate for Payer: Humana Medicare |
$6.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.47
|
| Rate for Payer: MDX Hawaii PPO |
$12.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.47
|
| Rate for Payer: University Health Alliance Commercial |
$9.44
|
|
|
PP acetaminoph 120 mg supp #4 [HHSC]
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530909
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.01 |
| Max. Negotiated Rate |
$12.56 |
| Rate for Payer: Cash Price |
$8.42
|
| Rate for Payer: Health Management Network Commercial |
$11.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.65
|
| Rate for Payer: MDX Hawaii PPO |
$12.56
|
|
|
PP acetaminoph 160 mg/5 mL 120mL [HHSC]
|
Facility
|
OP
|
$986.79
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530968
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$493.39 |
| Max. Negotiated Rate |
$957.19 |
| Rate for Payer: AlohaCare Medicaid |
$493.39
|
| Rate for Payer: AlohaCare Medicaid |
$22.34
|
| Rate for Payer: AlohaCare Medicaid |
$19.93
|
| Rate for Payer: AlohaCare Medicaid |
$8.39
|
| Rate for Payer: AlohaCare Medicaid |
$16.38
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$493.39
|
| Rate for Payer: AlohaCare Medicare |
$16.38
|
| Rate for Payer: AlohaCare Medicare |
$19.93
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$22.34
|
| Rate for Payer: AlohaCare Medicare |
$8.39
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$21.29
|
| Rate for Payer: Cash Price |
$29.05
|
| Rate for Payer: Cash Price |
$641.41
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: Devoted Health Medicare |
$542.73
|
| Rate for Payer: Devoted Health Medicare |
$24.58
|
| Rate for Payer: Devoted Health Medicare |
$21.92
|
| Rate for Payer: Devoted Health Medicare |
$9.23
|
| Rate for Payer: Devoted Health Medicare |
$18.01
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$493.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$937.45
|
| Rate for Payer: Health Management Network Commercial |
$37.99
|
| Rate for Payer: Health Management Network Commercial |
$27.84
|
| Rate for Payer: Health Management Network Commercial |
$33.87
|
| Rate for Payer: Health Management Network Commercial |
$14.27
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$838.77
|
| Rate for Payer: Humana Medicare |
$22.34
|
| Rate for Payer: Humana Medicare |
$8.39
|
| Rate for Payer: Humana Medicare |
$19.93
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$16.38
|
| Rate for Payer: Humana Medicare |
$493.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$888.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$503.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$493.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.34
|
| Rate for Payer: MDX Hawaii PPO |
$16.29
|
| Rate for Payer: MDX Hawaii PPO |
$38.65
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$43.35
|
| Rate for Payer: MDX Hawaii PPO |
$957.19
|
| Rate for Payer: MDX Hawaii PPO |
$31.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$493.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$493.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$493.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.39
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$32.57
|
| Rate for Payer: University Health Alliance Commercial |
$719.27
|
| Rate for Payer: University Health Alliance Commercial |
$29.05
|
| Rate for Payer: University Health Alliance Commercial |
$12.24
|
| Rate for Payer: University Health Alliance Commercial |
$23.87
|
|
|
PP acetaminoph 160 mg/5 mL 120mL [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530968
|
|
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 |
$10.91
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$29.05
|
| Rate for Payer: Cash Price |
$641.41
|
| Rate for Payer: Cash Price |
$21.29
|
| Rate for Payer: Health Management Network Commercial |
$27.84
|
| Rate for Payer: Health Management Network Commercial |
$37.99
|
| Rate for Payer: Health Management Network Commercial |
$33.87
|
| Rate for Payer: Health Management Network Commercial |
$838.77
|
| Rate for Payer: Health Management Network Commercial |
$14.27
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$888.11
|
| Rate for Payer: MDX Hawaii PPO |
$31.77
|
| Rate for Payer: MDX Hawaii PPO |
$43.35
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$16.29
|
| Rate for Payer: MDX Hawaii PPO |
$957.19
|
| Rate for Payer: MDX Hawaii PPO |
$38.65
|
|
|
PP acetaminoph 325 mg supp #4 [HHSC]
|
Facility
|
OP
|
$14.62
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530917
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$14.18 |
| Rate for Payer: AlohaCare Medicaid |
$7.31
|
| Rate for Payer: AlohaCare Medicare |
$7.31
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Devoted Health Medicare |
$8.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.89
|
| Rate for Payer: Health Management Network Commercial |
$12.43
|
| Rate for Payer: Humana Medicare |
$7.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.31
|
| Rate for Payer: MDX Hawaii PPO |
$14.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.31
|
| Rate for Payer: University Health Alliance Commercial |
$10.66
|
|
|
PP acetaminoph 325 mg supp #4 [HHSC]
|
Facility
|
IP
|
$14.62
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530917
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$14.18 |
| Rate for Payer: Kaiser Permanente Commercial |
$13.16
|
| Rate for Payer: Cash Price |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$12.43
|
| Rate for Payer: MDX Hawaii PPO |
$14.18
|
|
|
PP acetaminop infant 160mg/5mL 30mL [HHSC]
|
Facility
|
IP
|
$44.70
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530981
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.99 |
| Max. Negotiated Rate |
$43.36 |
| Rate for Payer: Cash Price |
$29.06
|
| Rate for Payer: Cash Price |
$17.67
|
| Rate for Payer: Health Management Network Commercial |
$37.99
|
| Rate for Payer: Health Management Network Commercial |
$23.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.47
|
| Rate for Payer: MDX Hawaii PPO |
$26.37
|
| Rate for Payer: MDX Hawaii PPO |
$43.36
|
|
|
PP acetaminop infant 160mg/5mL 30mL [HHSC]
|
Facility
|
OP
|
$27.19
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530981
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$26.37 |
| Rate for Payer: AlohaCare Medicaid |
$13.60
|
| Rate for Payer: AlohaCare Medicaid |
$22.35
|
| Rate for Payer: AlohaCare Medicare |
$13.60
|
| Rate for Payer: AlohaCare Medicare |
$22.35
|
| Rate for Payer: Cash Price |
$29.06
|
| Rate for Payer: Cash Price |
$17.67
|
| Rate for Payer: Devoted Health Medicare |
$14.95
|
| Rate for Payer: Devoted Health Medicare |
$24.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.83
|
| Rate for Payer: Health Management Network Commercial |
$23.11
|
| Rate for Payer: Health Management Network Commercial |
$37.99
|
| Rate for Payer: Humana Medicare |
$22.35
|
| Rate for Payer: Humana Medicare |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$43.36
|
| Rate for Payer: MDX Hawaii PPO |
$26.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.35
|
| Rate for Payer: University Health Alliance Commercial |
$32.58
|
| Rate for Payer: University Health Alliance Commercial |
$19.82
|
|
|
PP albuterol 90mcg/inh 8gm inhaler [HHSC]
|
Facility
|
OP
|
$132.10
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
2530920
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$66.05 |
| Max. Negotiated Rate |
$128.14 |
| Rate for Payer: AlohaCare Medicaid |
$66.05
|
| Rate for Payer: AlohaCare Medicare |
$66.05
|
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Devoted Health Medicare |
$72.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.50
|
| Rate for Payer: Health Management Network Commercial |
$112.28
|
| Rate for Payer: Humana Medicare |
$66.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.05
|
| Rate for Payer: MDX Hawaii PPO |
$128.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.05
|
| Rate for Payer: University Health Alliance Commercial |
$96.29
|
|
|
PP albuterol 90mcg/inh 8gm inhaler [HHSC]
|
Facility
|
IP
|
$132.10
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
2530920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.28 |
| Max. Negotiated Rate |
$128.14 |
| Rate for Payer: Cash Price |
$85.86
|
| Rate for Payer: Health Management Network Commercial |
$112.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.89
|
| Rate for Payer: MDX Hawaii PPO |
$128.14
|
|
|
PP amox-clav 250mg/5mL 100mL [HHSC]
|
Facility
|
OP
|
$545.38
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530921
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$272.69 |
| Max. Negotiated Rate |
$529.02 |
| Rate for Payer: AlohaCare Medicaid |
$272.69
|
| Rate for Payer: AlohaCare Medicaid |
$200.60
|
| Rate for Payer: AlohaCare Medicare |
$200.60
|
| Rate for Payer: AlohaCare Medicare |
$272.69
|
| Rate for Payer: Cash Price |
$260.79
|
| Rate for Payer: Cash Price |
$354.50
|
| Rate for Payer: Devoted Health Medicare |
$299.96
|
| Rate for Payer: Devoted Health Medicare |
$220.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$200.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$272.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$381.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$518.11
|
| Rate for Payer: Health Management Network Commercial |
$463.57
|
| Rate for Payer: Health Management Network Commercial |
$341.03
|
| Rate for Payer: Humana Medicare |
$272.69
|
| Rate for Payer: Humana Medicare |
$200.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$490.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$278.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$204.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$200.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$272.69
|
| Rate for Payer: MDX Hawaii PPO |
$389.17
|
| Rate for Payer: MDX Hawaii PPO |
$529.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$200.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$272.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$200.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$272.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$272.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$200.60
|
| Rate for Payer: University Health Alliance Commercial |
$397.53
|
| Rate for Payer: University Health Alliance Commercial |
$292.44
|
|
|
PP amox-clav 250mg/5mL 100mL [HHSC]
|
Facility
|
IP
|
$401.21
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530921
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$341.03 |
| Max. Negotiated Rate |
$389.17 |
| Rate for Payer: Cash Price |
$260.79
|
| Rate for Payer: Cash Price |
$354.50
|
| Rate for Payer: Health Management Network Commercial |
$341.03
|
| Rate for Payer: Health Management Network Commercial |
$463.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$361.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$490.84
|
| Rate for Payer: MDX Hawaii PPO |
$529.02
|
| Rate for Payer: MDX Hawaii PPO |
$389.17
|
|
|
PP amox-clav 875-125 mg tab #2 [HHSC]
|
Facility
|
IP
|
$58.88
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.05 |
| Max. Negotiated Rate |
$57.11 |
| Rate for Payer: Cash Price |
$38.27
|
| Rate for Payer: Health Management Network Commercial |
$50.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.99
|
| Rate for Payer: MDX Hawaii PPO |
$57.11
|
|
|
PP amox-clav 875-125 mg tab #2 [HHSC]
|
Facility
|
OP
|
$58.88
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530925
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$29.44 |
| Max. Negotiated Rate |
$57.11 |
| Rate for Payer: AlohaCare Medicaid |
$29.44
|
| Rate for Payer: AlohaCare Medicare |
$29.44
|
| Rate for Payer: Cash Price |
$38.27
|
| Rate for Payer: Devoted Health Medicare |
$32.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.94
|
| Rate for Payer: Health Management Network Commercial |
$50.05
|
| Rate for Payer: Humana Medicare |
$29.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.44
|
| Rate for Payer: MDX Hawaii PPO |
$57.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.44
|
| Rate for Payer: University Health Alliance Commercial |
$42.92
|
|
|
PP amoxicil 400mg/5mL 100mL [HHSC]
|
Facility
|
OP
|
$57.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530923
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$28.73 |
| Max. Negotiated Rate |
$55.73 |
| Rate for Payer: AlohaCare Medicaid |
$28.73
|
| Rate for Payer: AlohaCare Medicare |
$28.73
|
| Rate for Payer: Cash Price |
$37.34
|
| Rate for Payer: Devoted Health Medicare |
$31.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.58
|
| Rate for Payer: Health Management Network Commercial |
$48.83
|
| Rate for Payer: Humana Medicare |
$28.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.73
|
| Rate for Payer: MDX Hawaii PPO |
$55.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.73
|
| Rate for Payer: University Health Alliance Commercial |
$41.88
|
|
|
PP amoxicil 400mg/5mL 100mL [HHSC]
|
Facility
|
IP
|
$57.45
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.83 |
| Max. Negotiated Rate |
$55.73 |
| Rate for Payer: Cash Price |
$37.34
|
| Rate for Payer: Health Management Network Commercial |
$48.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.70
|
| Rate for Payer: MDX Hawaii PPO |
$55.73
|
|
|
PP amoxicillin 500 mg cap #4 [HHSC]
|
Facility
|
IP
|
$9.65
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Health Management Network Commercial |
$8.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.69
|
| Rate for Payer: MDX Hawaii PPO |
$9.36
|
|
|
PP amoxicillin 500 mg cap #4 [HHSC]
|
Facility
|
OP
|
$9.65
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530910
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$9.36 |
| Rate for Payer: AlohaCare Medicaid |
$4.83
|
| Rate for Payer: AlohaCare Medicare |
$4.83
|
| Rate for Payer: Cash Price |
$6.27
|
| Rate for Payer: Devoted Health Medicare |
$5.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.17
|
| Rate for Payer: Health Management Network Commercial |
$8.20
|
| Rate for Payer: Humana Medicare |
$4.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.83
|
| Rate for Payer: MDX Hawaii PPO |
$9.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.83
|
| Rate for Payer: University Health Alliance Commercial |
$7.03
|
|
|
PP azithromycin 200 mg/5 mL 30 mL [HHSC]
|
Facility
|
OP
|
$163.95
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530970
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$81.97 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: AlohaCare Medicaid |
$81.97
|
| Rate for Payer: AlohaCare Medicaid |
$82.00
|
| Rate for Payer: AlohaCare Medicare |
$81.97
|
| Rate for Payer: AlohaCare Medicare |
$82.00
|
| Rate for Payer: Cash Price |
$106.59
|
| Rate for Payer: Cash Price |
$106.57
|
| Rate for Payer: Devoted Health Medicare |
$90.17
|
| Rate for Payer: Devoted Health Medicare |
$90.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.75
|
| Rate for Payer: Health Management Network Commercial |
$139.36
|
| Rate for Payer: Health Management Network Commercial |
$139.39
|
| Rate for Payer: Humana Medicare |
$82.00
|
| Rate for Payer: Humana Medicare |
$81.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.97
|
| Rate for Payer: MDX Hawaii PPO |
$159.07
|
| Rate for Payer: MDX Hawaii PPO |
$159.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.00
|
| Rate for Payer: University Health Alliance Commercial |
$119.53
|
| Rate for Payer: University Health Alliance Commercial |
$119.50
|
|
