|
PP doxycycline 100 mg tab #2 [HHSC]
|
Facility
|
OP
|
$64.86
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530916
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$32.43 |
| Max. Negotiated Rate |
$62.91 |
| Rate for Payer: AlohaCare Medicaid |
$32.43
|
| Rate for Payer: AlohaCare Medicare |
$32.43
|
| Rate for Payer: Cash Price |
$42.16
|
| Rate for Payer: Devoted Health Medicare |
$35.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.62
|
| Rate for Payer: Health Management Network Commercial |
$55.13
|
| Rate for Payer: Humana Medicare |
$32.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.43
|
| Rate for Payer: MDX Hawaii PPO |
$62.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.43
|
| Rate for Payer: University Health Alliance Commercial |
$47.28
|
|
|
PP doxycycline 100 mg tab #2 [HHSC]
|
Facility
|
IP
|
$64.86
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.13 |
| Max. Negotiated Rate |
$62.91 |
| Rate for Payer: Cash Price |
$42.16
|
| Rate for Payer: Health Management Network Commercial |
$55.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.37
|
| Rate for Payer: MDX Hawaii PPO |
$62.91
|
|
|
PP emtricitabine-tenofovir 200 mg-300 mg #1 [HHSC]
|
Facility
|
OP
|
$408.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531071
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$204.13 |
| Max. Negotiated Rate |
$396.02 |
| Rate for Payer: AlohaCare Medicaid |
$204.13
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$172.03
|
| Rate for Payer: AlohaCare Medicare |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$204.13
|
| Rate for Payer: AlohaCare Medicare |
$172.03
|
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$265.38
|
| Rate for Payer: Devoted Health Medicare |
$189.23
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Devoted Health Medicare |
$224.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$204.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$326.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$387.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.34
|
| Rate for Payer: Health Management Network Commercial |
$11.04
|
| Rate for Payer: Health Management Network Commercial |
$347.03
|
| Rate for Payer: Health Management Network Commercial |
$292.44
|
| Rate for Payer: Humana Medicare |
$6.50
|
| Rate for Payer: Humana Medicare |
$172.03
|
| Rate for Payer: Humana Medicare |
$204.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$367.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$208.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$175.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$204.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.03
|
| Rate for Payer: MDX Hawaii PPO |
$396.02
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$204.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$204.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$204.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.50
|
| Rate for Payer: University Health Alliance Commercial |
$297.59
|
| Rate for Payer: University Health Alliance Commercial |
$9.47
|
| Rate for Payer: University Health Alliance Commercial |
$250.78
|
|
|
PP emtricitabine-tenofovir 200 mg-300 mg #1 [HHSC]
|
Facility
|
IP
|
$408.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$347.03 |
| Max. Negotiated Rate |
$396.02 |
| Rate for Payer: Cash Price |
$265.38
|
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Health Management Network Commercial |
$347.03
|
| Rate for Payer: Health Management Network Commercial |
$11.04
|
| Rate for Payer: Health Management Network Commercial |
$292.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$367.44
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$396.02
|
|
|
PP epinephrine 0.3mg auto-inj (#2) [HHSC]
|
Facility
|
IP
|
$1,692.06
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2530931
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,438.25 |
| Max. Negotiated Rate |
$1,641.30 |
| Rate for Payer: Cash Price |
$1,099.84
|
| Rate for Payer: Cash Price |
$666.74
|
| Rate for Payer: Health Management Network Commercial |
$1,438.25
|
| Rate for Payer: Health Management Network Commercial |
$871.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,522.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$923.17
|
| Rate for Payer: MDX Hawaii PPO |
$994.98
|
| Rate for Payer: MDX Hawaii PPO |
$1,641.30
|
|
|
PP epinephrine 0.3mg auto-inj (#2) [HHSC]
|
Facility
|
OP
|
$1,025.75
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2530931
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$512.88 |
| Max. Negotiated Rate |
$994.98 |
| Rate for Payer: AlohaCare Medicaid |
$512.88
|
| Rate for Payer: AlohaCare Medicaid |
$846.03
|
| Rate for Payer: AlohaCare Medicare |
$512.88
|
| Rate for Payer: AlohaCare Medicare |
$846.03
|
| Rate for Payer: Cash Price |
$1,099.84
|
| Rate for Payer: Cash Price |
$666.74
|
| Rate for Payer: Devoted Health Medicare |
$564.16
|
| Rate for Payer: Devoted Health Medicare |
$930.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$846.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$512.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,607.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$974.46
|
| Rate for Payer: Health Management Network Commercial |
$871.89
|
| Rate for Payer: Health Management Network Commercial |
$1,438.25
|
| Rate for Payer: Humana Medicare |
$846.03
|
| Rate for Payer: Humana Medicare |
$512.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$923.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,522.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$862.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$523.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$846.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$512.88
|
| Rate for Payer: MDX Hawaii PPO |
$1,641.30
|
| Rate for Payer: MDX Hawaii PPO |
$994.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$512.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$846.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$512.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$846.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$512.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$846.03
|
| Rate for Payer: University Health Alliance Commercial |
$1,233.34
|
| Rate for Payer: University Health Alliance Commercial |
$747.67
|
|
|
PP erythromyc oph oint 3.5gm [HHSC]
|
Facility
|
IP
|
$96.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.91 |
| Max. Negotiated Rate |
$93.47 |
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Health Management Network Commercial |
$81.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: MDX Hawaii PPO |
$93.47
|
|
|
PP erythromyc oph oint 3.5gm [HHSC]
|
Facility
|
OP
|
$96.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530932
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$48.18 |
| Max. Negotiated Rate |
$93.47 |
| Rate for Payer: AlohaCare Medicaid |
$48.18
|
| Rate for Payer: AlohaCare Medicare |
$48.18
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Devoted Health Medicare |
$53.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.54
|
| Rate for Payer: Health Management Network Commercial |
$81.91
|
| Rate for Payer: Humana Medicare |
$48.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.18
|
| Rate for Payer: MDX Hawaii PPO |
$93.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.18
|
| Rate for Payer: University Health Alliance Commercial |
$70.24
|
|
|
PP famotidine 20 mg tab #2 [HHSC]
|
Facility
|
OP
|
$26.93
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531010
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$13.46 |
| Max. Negotiated Rate |
$26.12 |
| Rate for Payer: AlohaCare Medicaid |
$13.46
|
| Rate for Payer: AlohaCare Medicare |
$13.46
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Devoted Health Medicare |
$14.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.58
|
| Rate for Payer: Health Management Network Commercial |
$22.89
|
| Rate for Payer: Humana Medicare |
$13.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.46
|
| Rate for Payer: MDX Hawaii PPO |
$26.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.46
|
| Rate for Payer: University Health Alliance Commercial |
$19.63
|
|
|
PP famotidine 20 mg tab #2 [HHSC]
|
Facility
|
IP
|
$26.93
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.89 |
| Max. Negotiated Rate |
$26.12 |
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Health Management Network Commercial |
$22.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.24
|
| Rate for Payer: MDX Hawaii PPO |
$26.12
|
|
|
PP gentamicin 0.3% oph drops 5mL [HHSC]
|
Facility
|
IP
|
$98.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
|
|
PP gentamicin 0.3% oph drops 5mL [HHSC]
|
Facility
|
OP
|
$98.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530933
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$49.16 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: AlohaCare Medicaid |
$49.16
|
| Rate for Payer: AlohaCare Medicare |
$49.16
|
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Devoted Health Medicare |
$54.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.40
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Humana Medicare |
$49.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.16
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.16
|
| Rate for Payer: University Health Alliance Commercial |
$71.67
|
|
|
PP guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]
|
Facility
|
OP
|
$44.15
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531123
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$22.07 |
| Max. Negotiated Rate |
$42.83 |
| Rate for Payer: AlohaCare Medicaid |
$22.07
|
| Rate for Payer: AlohaCare Medicaid |
$21.64
|
| Rate for Payer: AlohaCare Medicaid |
$22.05
|
| Rate for Payer: AlohaCare Medicare |
$21.64
|
| Rate for Payer: AlohaCare Medicare |
$22.07
|
| Rate for Payer: AlohaCare Medicare |
$22.05
|
| Rate for Payer: Cash Price |
$28.67
|
| Rate for Payer: Cash Price |
$28.13
|
| Rate for Payer: Cash Price |
$28.70
|
| Rate for Payer: Devoted Health Medicare |
$24.25
|
| Rate for Payer: Devoted Health Medicare |
$23.80
|
| Rate for Payer: Devoted Health Medicare |
$24.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.12
|
| Rate for Payer: Health Management Network Commercial |
$36.79
|
| Rate for Payer: Health Management Network Commercial |
$37.53
|
| Rate for Payer: Health Management Network Commercial |
$37.48
|
| Rate for Payer: Humana Medicare |
$21.64
|
| Rate for Payer: Humana Medicare |
$22.05
|
| Rate for Payer: Humana Medicare |
$22.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.05
|
| Rate for Payer: MDX Hawaii PPO |
$42.83
|
| Rate for Payer: MDX Hawaii PPO |
$42.78
|
| Rate for Payer: MDX Hawaii PPO |
$41.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.64
|
| Rate for Payer: University Health Alliance Commercial |
$32.18
|
| Rate for Payer: University Health Alliance Commercial |
$31.55
|
| Rate for Payer: University Health Alliance Commercial |
$32.14
|
|
|
PP guaiFEN-cod 100-10 mg/5 mL 60 mL [HHSC]
|
Facility
|
IP
|
$44.15
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531123
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.53 |
| Max. Negotiated Rate |
$42.83 |
| Rate for Payer: Cash Price |
$28.70
|
| Rate for Payer: Cash Price |
$28.67
|
| Rate for Payer: Cash Price |
$28.13
|
| Rate for Payer: Health Management Network Commercial |
$37.53
|
| Rate for Payer: Health Management Network Commercial |
$36.79
|
| Rate for Payer: Health Management Network Commercial |
$37.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.73
|
| Rate for Payer: MDX Hawaii PPO |
$42.78
|
| Rate for Payer: MDX Hawaii PPO |
$41.98
|
| Rate for Payer: MDX Hawaii PPO |
$42.83
|
|
|
PP guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
OP
|
$6.91
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530934
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: AlohaCare Medicaid |
$3.46
|
| Rate for Payer: AlohaCare Medicare |
$3.46
|
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Devoted Health Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.56
|
| Rate for Payer: Health Management Network Commercial |
$5.87
|
| Rate for Payer: Humana Medicare |
$3.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.46
|
| Rate for Payer: MDX Hawaii PPO |
$6.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.46
|
| Rate for Payer: University Health Alliance Commercial |
$5.04
|
|
|
PP guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904005300R
|
| Hospital Charge Code |
2530934
|
|
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 guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904005300R
|
| Hospital Charge Code |
2530934
|
|
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
|
|
|
PP guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
IP
|
$6.91
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Health Management Network Commercial |
$5.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.22
|
| Rate for Payer: MDX Hawaii PPO |
$6.70
|
|
|
PP hydrocod/APAP 5/325 mg #3 [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530935
|
|
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 |
$8.63
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$11.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.94
|
| Rate for Payer: MDX Hawaii PPO |
$12.87
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PP hydrocod/APAP 5/325 mg #3 [HHSC]
|
Facility
|
OP
|
$13.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530935
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.87 |
| Rate for Payer: AlohaCare Medicaid |
$6.63
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$6.63
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Devoted Health Medicare |
$7.30
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.61
|
| Rate for Payer: Health Management Network Commercial |
$11.28
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$6.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$12.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$9.67
|
|
|
PP hydrocod/APAP 5/325 mg #6 [HHSC]
|
Facility
|
OP
|
$26.53
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530936
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$25.73 |
| Rate for Payer: AlohaCare Medicaid |
$13.27
|
| Rate for Payer: AlohaCare Medicare |
$13.27
|
| Rate for Payer: Cash Price |
$17.24
|
| Rate for Payer: Devoted Health Medicare |
$14.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$22.55
|
| Rate for Payer: Humana Medicare |
$13.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.27
|
| Rate for Payer: MDX Hawaii PPO |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.27
|
| Rate for Payer: University Health Alliance Commercial |
$19.34
|
|
|
PP hydrocod/APAP 5/325 mg #6 [HHSC]
|
Facility
|
IP
|
$26.53
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$25.73 |
| Rate for Payer: Cash Price |
$17.24
|
| Rate for Payer: Health Management Network Commercial |
$22.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.88
|
| Rate for Payer: MDX Hawaii PPO |
$25.73
|
|
|
PP ibuprofen 100 mg/5 mL 118mL [HHSC]
|
Facility
|
IP
|
$23.45
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.93 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Cash Price |
$19.48
|
| Rate for Payer: Cash Price |
$25.87
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: Health Management Network Commercial |
$23.52
|
| Rate for Payer: Health Management Network Commercial |
$33.83
|
| Rate for Payer: Health Management Network Commercial |
$25.47
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Health Management Network Commercial |
$19.19
|
| Rate for Payer: Health Management Network Commercial |
$19.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: MDX Hawaii PPO |
$26.84
|
| Rate for Payer: MDX Hawaii PPO |
$38.61
|
| Rate for Payer: MDX Hawaii PPO |
$22.75
|
| Rate for Payer: MDX Hawaii PPO |
$21.90
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.07
|
|
|
PP ibuprofen 100 mg/5 mL 118mL [HHSC]
|
Facility
|
OP
|
$53.61
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530938
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$26.80 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: AlohaCare Medicaid |
$26.80
|
| Rate for Payer: AlohaCare Medicaid |
$19.90
|
| Rate for Payer: AlohaCare Medicaid |
$14.98
|
| Rate for Payer: AlohaCare Medicaid |
$11.29
|
| Rate for Payer: AlohaCare Medicaid |
$13.84
|
| Rate for Payer: AlohaCare Medicaid |
$11.72
|
| Rate for Payer: AlohaCare Medicare |
$26.80
|
| Rate for Payer: AlohaCare Medicare |
$13.84
|
| Rate for Payer: AlohaCare Medicare |
$14.98
|
| Rate for Payer: AlohaCare Medicare |
$11.72
|
| Rate for Payer: AlohaCare Medicare |
$19.90
|
| Rate for Payer: AlohaCare Medicare |
$11.29
|
| Rate for Payer: Cash Price |
$19.48
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: Cash Price |
$25.87
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Devoted Health Medicare |
$29.49
|
| Rate for Payer: Devoted Health Medicare |
$21.89
|
| Rate for Payer: Devoted Health Medicare |
$16.48
|
| Rate for Payer: Devoted Health Medicare |
$12.42
|
| Rate for Payer: Devoted Health Medicare |
$15.22
|
| Rate for Payer: Devoted Health Medicare |
$12.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.93
|
| Rate for Payer: Health Management Network Commercial |
$33.83
|
| Rate for Payer: Health Management Network Commercial |
$23.52
|
| Rate for Payer: Health Management Network Commercial |
$25.47
|
| Rate for Payer: Health Management Network Commercial |
$19.19
|
| Rate for Payer: Health Management Network Commercial |
$19.93
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Humana Medicare |
$19.90
|
| Rate for Payer: Humana Medicare |
$11.29
|
| Rate for Payer: Humana Medicare |
$14.98
|
| Rate for Payer: Humana Medicare |
$11.72
|
| Rate for Payer: Humana Medicare |
$13.84
|
| Rate for Payer: Humana Medicare |
$26.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.90
|
| Rate for Payer: MDX Hawaii PPO |
$21.90
|
| Rate for Payer: MDX Hawaii PPO |
$29.07
|
| Rate for Payer: MDX Hawaii PPO |
$22.75
|
| Rate for Payer: MDX Hawaii PPO |
$38.61
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$26.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.29
|
| Rate for Payer: University Health Alliance Commercial |
$17.09
|
| Rate for Payer: University Health Alliance Commercial |
$29.01
|
| Rate for Payer: University Health Alliance Commercial |
$39.08
|
| Rate for Payer: University Health Alliance Commercial |
$21.85
|
| Rate for Payer: University Health Alliance Commercial |
$16.46
|
| Rate for Payer: University Health Alliance Commercial |
$20.17
|
|
|
PP ibuprofen 400 mg tab #3 [HHSC]
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530939
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: AlohaCare Medicaid |
$2.17
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Devoted Health Medicare |
$2.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.12
|
| Rate for Payer: Health Management Network Commercial |
$3.69
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$4.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$3.16
|
|
