|
PP azithromycin 200 mg/5 mL 30 mL [HHSC]
|
Facility
|
IP
|
$163.99
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.39 |
| Max. Negotiated Rate |
$159.07 |
| Rate for Payer: Cash Price |
$106.59
|
| Rate for Payer: Cash Price |
$106.57
|
| Rate for Payer: Health Management Network Commercial |
$139.39
|
| Rate for Payer: Health Management Network Commercial |
$139.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.56
|
| Rate for Payer: MDX Hawaii PPO |
$159.03
|
| Rate for Payer: MDX Hawaii PPO |
$159.07
|
|
|
PP cefpodoxime 200 mg tab #2 [HHSC]
|
Facility
|
OP
|
$88.85
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531099
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$44.42 |
| Max. Negotiated Rate |
$86.18 |
| Rate for Payer: AlohaCare Medicaid |
$44.42
|
| Rate for Payer: AlohaCare Medicare |
$44.42
|
| Rate for Payer: Cash Price |
$57.75
|
| Rate for Payer: Devoted Health Medicare |
$48.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$84.41
|
| Rate for Payer: Health Management Network Commercial |
$75.52
|
| Rate for Payer: Humana Medicare |
$44.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.42
|
| Rate for Payer: MDX Hawaii PPO |
$86.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.42
|
| Rate for Payer: University Health Alliance Commercial |
$64.76
|
|
|
PP cefpodoxime 200 mg tab #2 [HHSC]
|
Facility
|
IP
|
$88.85
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531099
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.52 |
| Max. Negotiated Rate |
$86.18 |
| Rate for Payer: Cash Price |
$57.75
|
| Rate for Payer: Health Management Network Commercial |
$75.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.97
|
| Rate for Payer: MDX Hawaii PPO |
$86.18
|
|
|
PP cephalexin 250mg/5mL 100mL [HHSC]
|
Facility
|
IP
|
$138.32
|
|
|
Service Code
|
NDC 00093417773R
|
| Hospital Charge Code |
2530928
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.57 |
| Max. Negotiated Rate |
$134.17 |
| Rate for Payer: Cash Price |
$89.91
|
| Rate for Payer: Health Management Network Commercial |
$117.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.49
|
| Rate for Payer: MDX Hawaii PPO |
$134.17
|
|
|
PP cephalexin 250mg/5mL 100mL [HHSC]
|
Facility
|
OP
|
$138.32
|
|
|
Service Code
|
NDC 00093417773R
|
| Hospital Charge Code |
2530928
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$69.16 |
| Max. Negotiated Rate |
$134.17 |
| Rate for Payer: AlohaCare Medicaid |
$69.16
|
| Rate for Payer: AlohaCare Medicare |
$69.16
|
| Rate for Payer: Cash Price |
$89.91
|
| Rate for Payer: Devoted Health Medicare |
$76.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.40
|
| Rate for Payer: Health Management Network Commercial |
$117.57
|
| Rate for Payer: Humana Medicare |
$69.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.16
|
| Rate for Payer: MDX Hawaii PPO |
$134.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.16
|
| Rate for Payer: University Health Alliance Commercial |
$100.82
|
|
|
PP cephalexin 500 mg cap #4 [HHSC]
|
Facility
|
IP
|
$30.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$29.68 |
| Rate for Payer: Cash Price |
$19.89
|
| Rate for Payer: Cash Price |
$19.55
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Health Management Network Commercial |
$26.01
|
| Rate for Payer: Health Management Network Commercial |
$25.14
|
| Rate for Payer: Health Management Network Commercial |
$25.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.54
|
| Rate for Payer: MDX Hawaii PPO |
$29.17
|
| Rate for Payer: MDX Hawaii PPO |
$28.69
|
| Rate for Payer: MDX Hawaii PPO |
$29.68
|
|
|
PP cephalexin 500 mg cap #4 [HHSC]
|
Facility
|
OP
|
$30.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530912
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$29.68 |
| Rate for Payer: AlohaCare Medicaid |
$15.30
|
| Rate for Payer: AlohaCare Medicaid |
$14.79
|
| Rate for Payer: AlohaCare Medicaid |
$15.04
|
| Rate for Payer: AlohaCare Medicare |
$14.79
|
| Rate for Payer: AlohaCare Medicare |
$15.30
|
| Rate for Payer: AlohaCare Medicare |
$15.04
|
| Rate for Payer: Cash Price |
$19.55
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Cash Price |
$19.89
|
| Rate for Payer: Devoted Health Medicare |
$16.54
|
| Rate for Payer: Devoted Health Medicare |
$16.27
|
| Rate for Payer: Devoted Health Medicare |
$16.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.10
|
| Rate for Payer: Health Management Network Commercial |
$25.14
|
| Rate for Payer: Health Management Network Commercial |
$26.01
|
| Rate for Payer: Health Management Network Commercial |
$25.56
|
| Rate for Payer: Humana Medicare |
$14.79
|
| Rate for Payer: Humana Medicare |
$15.04
|
| Rate for Payer: Humana Medicare |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.04
|
| Rate for Payer: MDX Hawaii PPO |
$29.68
|
| Rate for Payer: MDX Hawaii PPO |
$29.17
|
| Rate for Payer: MDX Hawaii PPO |
$28.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.79
|
| Rate for Payer: University Health Alliance Commercial |
$22.30
|
| Rate for Payer: University Health Alliance Commercial |
$21.56
|
| Rate for Payer: University Health Alliance Commercial |
$21.92
|
|
|
PP chlordiazePOXIDE 25 mg cap #4 [HHSC]
|
Facility
|
OP
|
$14.87
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531100
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.43 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: AlohaCare Medicaid |
$7.43
|
| Rate for Payer: AlohaCare Medicaid |
$8.84
|
| Rate for Payer: AlohaCare Medicare |
$7.43
|
| Rate for Payer: AlohaCare Medicare |
$8.84
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$9.67
|
| Rate for Payer: Devoted Health Medicare |
$8.18
|
| Rate for Payer: Devoted Health Medicare |
$9.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.13
|
| Rate for Payer: Health Management Network Commercial |
$12.64
|
| Rate for Payer: Health Management Network Commercial |
$15.02
|
| Rate for Payer: Humana Medicare |
$8.84
|
| Rate for Payer: Humana Medicare |
$7.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.43
|
| Rate for Payer: MDX Hawaii PPO |
$17.14
|
| Rate for Payer: MDX Hawaii PPO |
$14.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.84
|
| Rate for Payer: University Health Alliance Commercial |
$12.88
|
| Rate for Payer: University Health Alliance Commercial |
$10.84
|
|
|
PP chlordiazePOXIDE 25 mg cap #4 [HHSC]
|
Facility
|
IP
|
$17.67
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.02 |
| Max. Negotiated Rate |
$17.14 |
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$9.67
|
| Rate for Payer: Health Management Network Commercial |
$15.02
|
| Rate for Payer: Health Management Network Commercial |
$12.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.38
|
| Rate for Payer: MDX Hawaii PPO |
$14.42
|
| Rate for Payer: MDX Hawaii PPO |
$17.14
|
|
|
PP ciprofloxacin 500 mg tab #2 [HHSC]
|
Facility
|
OP
|
$40.63
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530913
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$20.32 |
| Max. Negotiated Rate |
$39.41 |
| Rate for Payer: AlohaCare Medicaid |
$20.32
|
| Rate for Payer: AlohaCare Medicaid |
$32.45
|
| Rate for Payer: AlohaCare Medicare |
$20.32
|
| Rate for Payer: AlohaCare Medicare |
$32.45
|
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Cash Price |
$26.41
|
| Rate for Payer: Devoted Health Medicare |
$22.35
|
| Rate for Payer: Devoted Health Medicare |
$35.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.60
|
| Rate for Payer: Health Management Network Commercial |
$34.54
|
| Rate for Payer: Health Management Network Commercial |
$55.16
|
| Rate for Payer: Humana Medicare |
$32.45
|
| Rate for Payer: Humana Medicare |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.32
|
| Rate for Payer: MDX Hawaii PPO |
$62.94
|
| Rate for Payer: MDX Hawaii PPO |
$39.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.45
|
| Rate for Payer: University Health Alliance Commercial |
$47.30
|
| Rate for Payer: University Health Alliance Commercial |
$29.62
|
|
|
PP ciprofloxacin 500 mg tab #2 [HHSC]
|
Facility
|
IP
|
$64.89
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530913
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.16 |
| Max. Negotiated Rate |
$62.94 |
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Cash Price |
$26.41
|
| Rate for Payer: Health Management Network Commercial |
$55.16
|
| Rate for Payer: Health Management Network Commercial |
$34.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.57
|
| Rate for Payer: MDX Hawaii PPO |
$39.41
|
| Rate for Payer: MDX Hawaii PPO |
$62.94
|
|
|
PP clindamycin 300mg cap #4 [HHSC]
|
Facility
|
IP
|
$12.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: Health Management Network Commercial |
$10.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.01
|
| Rate for Payer: MDX Hawaii PPO |
$11.86
|
|
|
PP clindamycin 300mg cap #4 [HHSC]
|
Facility
|
OP
|
$12.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530929
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: AlohaCare Medicaid |
$6.12
|
| Rate for Payer: AlohaCare Medicare |
$6.12
|
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: Devoted Health Medicare |
$6.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.62
|
| Rate for Payer: Health Management Network Commercial |
$10.40
|
| Rate for Payer: Humana Medicare |
$6.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.12
|
| Rate for Payer: University Health Alliance Commercial |
$8.91
|
|
|
PP cyclobenzapr 10 mg tab #3 [HHSC]
|
Facility
|
IP
|
$16.16
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530914
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Health Management Network Commercial |
$13.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.54
|
| Rate for Payer: MDX Hawaii PPO |
$15.68
|
|
|
PP cyclobenzapr 10 mg tab #3 [HHSC]
|
Facility
|
OP
|
$16.16
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530914
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: AlohaCare Medicaid |
$8.08
|
| Rate for Payer: AlohaCare Medicare |
$8.08
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Devoted Health Medicare |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.35
|
| Rate for Payer: Health Management Network Commercial |
$13.74
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.08
|
| Rate for Payer: MDX Hawaii PPO |
$15.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.08
|
| Rate for Payer: University Health Alliance Commercial |
$11.78
|
|
|
PPD Administration POC
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
2562303
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
PPD Administration POC
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
4623202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
PPD Administration POC
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
4623202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$24.50
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Devoted Health Medicare |
$26.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$24.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.50
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
PPD Administration POC
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
2562303
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$36.50
|
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Devoted Health Medicare |
$40.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.55
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$36.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.50
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.50
|
| Rate for Payer: University Health Alliance Commercial |
$17.04
|
|
|
PP dicyclomine 20 mg tab #4 [HHSC]
|
Facility
|
OP
|
$17.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530915
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: AlohaCare Medicaid |
$8.63
|
| Rate for Payer: AlohaCare Medicare |
$8.63
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: Devoted Health Medicare |
$9.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.41
|
| Rate for Payer: Health Management Network Commercial |
$14.68
|
| Rate for Payer: Humana Medicare |
$8.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.63
|
| Rate for Payer: MDX Hawaii PPO |
$16.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.63
|
| Rate for Payer: University Health Alliance Commercial |
$12.59
|
|
|
PP dicyclomine 20 mg tab #4 [HHSC]
|
Facility
|
IP
|
$17.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: Health Management Network Commercial |
$14.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.54
|
| Rate for Payer: MDX Hawaii PPO |
$16.75
|
|
|
PP diphenhyd 12.5 mg/5 mL 60 mL [HHSC]
|
Facility
|
OP
|
$3.98
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530927
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: AlohaCare Medicaid |
$1.99
|
| Rate for Payer: AlohaCare Medicaid |
$6.33
|
| Rate for Payer: AlohaCare Medicaid |
$1.94
|
| Rate for Payer: AlohaCare Medicare |
$6.33
|
| Rate for Payer: AlohaCare Medicare |
$1.99
|
| Rate for Payer: AlohaCare Medicare |
$1.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Devoted Health Medicare |
$2.13
|
| Rate for Payer: Devoted Health Medicare |
$6.97
|
| Rate for Payer: Devoted Health Medicare |
$2.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.04
|
| Rate for Payer: Health Management Network Commercial |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$3.30
|
| Rate for Payer: Humana Medicare |
$6.33
|
| Rate for Payer: Humana Medicare |
$1.94
|
| Rate for Payer: Humana Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$3.86
|
| Rate for Payer: MDX Hawaii PPO |
$3.76
|
| Rate for Payer: MDX Hawaii PPO |
$12.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.33
|
| Rate for Payer: University Health Alliance Commercial |
$2.90
|
| Rate for Payer: University Health Alliance Commercial |
$9.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.83
|
|
|
PP diphenhyd 12.5 mg/5 mL 60 mL [HHSC]
|
Facility
|
IP
|
$3.98
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Health Management Network Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.58
|
| Rate for Payer: MDX Hawaii PPO |
$3.76
|
| Rate for Payer: MDX Hawaii PPO |
$12.29
|
| Rate for Payer: MDX Hawaii PPO |
$3.86
|
|
|
PP diphenhydram 25 mg cap #3 [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530911
|
|
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
|
|
|
PP diphenhydram 25 mg cap #3 [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530911
|
|
Hospital Revenue Code
|
253
|
| 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 Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
