Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PP ondansetron ODT 4 mg tab #2 [HHSC]

Facility

$204.52

Service Code	HCPCS J8499
Hospital Charge Code	2530949
Hospital Revenue Code	250
Min. Negotiated Rate	$173.84
Max. Negotiated Rate	$198.38
Rate for Payer: Cash Price	$132.94
Rate for Payer: Cash Price	$132.89
Rate for Payer: Health Management Network Commercial	$173.84
Rate for Payer: Health Management Network Commercial	$173.77
Rate for Payer: Kaiser Permanente Commercial	$184.07
Rate for Payer: Kaiser Permanente Commercial	$184.00
Rate for Payer: MDX Hawaii PPO	$198.31
Rate for Payer: MDX Hawaii PPO	$198.38

PP ondansetron ODT 4 mg tab #2 [HHSC]

Facility

$204.44

Service Code	HCPCS J8499
Hospital Charge Code	2530949
Hospital Revenue Code	253
Min. Negotiated Rate	$102.22
Max. Negotiated Rate	$198.31
Rate for Payer: AlohaCare Medicaid	$102.22
Rate for Payer: AlohaCare Medicaid	$102.26
Rate for Payer: AlohaCare Medicare	$102.22
Rate for Payer: AlohaCare Medicare	$102.26
Rate for Payer: Cash Price	$132.94
Rate for Payer: Cash Price	$132.89
Rate for Payer: Devoted Health Medicare	$112.44
Rate for Payer: Devoted Health Medicare	$112.49
Rate for Payer: Hawaii Medical Service Association Medicare	$102.26
Rate for Payer: Hawaii Medical Service Association Medicare	$102.22
Rate for Payer: Hawaii Western Management Group Commercial	$194.29
Rate for Payer: Hawaii Western Management Group Commercial	$194.22
Rate for Payer: Health Management Network Commercial	$173.77
Rate for Payer: Health Management Network Commercial	$173.84
Rate for Payer: Humana Medicare	$102.26
Rate for Payer: Humana Medicare	$102.22
Rate for Payer: Kaiser Permanente Commercial	$184.00
Rate for Payer: Kaiser Permanente Commercial	$184.07
Rate for Payer: Kaiser Permanente Medicaid	$104.31
Rate for Payer: Kaiser Permanente Medicaid	$104.26
Rate for Payer: Kaiser Permanente Medicare	$102.26
Rate for Payer: Kaiser Permanente Medicare	$102.22
Rate for Payer: MDX Hawaii PPO	$198.38
Rate for Payer: MDX Hawaii PPO	$198.31
Rate for Payer: Ohana Health Plan Medicaid	$102.22
Rate for Payer: Ohana Health Plan Medicaid	$102.26
Rate for Payer: Ohana Health Plan Medicare	$102.22
Rate for Payer: Ohana Health Plan Medicare	$102.26
Rate for Payer: UnitedHealthcare Medicare	$102.22
Rate for Payer: UnitedHealthcare Medicare	$102.26
Rate for Payer: University Health Alliance Commercial	$149.07
Rate for Payer: University Health Alliance Commercial	$149.02

PP oseltamivir 6 mg/mL 60 mL [HHSC]

Facility

$584.82

Service Code	HCPCS J8499
Hospital Charge Code	2530950
Hospital Revenue Code	253
Min. Negotiated Rate	$292.41
Max. Negotiated Rate	$567.28
Rate for Payer: AlohaCare Medicaid	$292.41
Rate for Payer: AlohaCare Medicare	$292.41
Rate for Payer: Cash Price	$380.13
Rate for Payer: Devoted Health Medicare	$321.65
Rate for Payer: Hawaii Medical Service Association Medicare	$292.41
Rate for Payer: Hawaii Western Management Group Commercial	$555.58
Rate for Payer: Health Management Network Commercial	$497.10
Rate for Payer: Humana Medicare	$292.41
Rate for Payer: Kaiser Permanente Commercial	$526.34
Rate for Payer: Kaiser Permanente Medicaid	$298.26
Rate for Payer: Kaiser Permanente Medicare	$292.41
Rate for Payer: MDX Hawaii PPO	$567.28
Rate for Payer: Ohana Health Plan Medicaid	$292.41
Rate for Payer: Ohana Health Plan Medicare	$292.41
Rate for Payer: UnitedHealthcare Medicare	$292.41
Rate for Payer: University Health Alliance Commercial	$426.28

PP oseltamivir 6 mg/mL 60 mL [HHSC]

Facility

$584.82

Service Code	HCPCS J8499
Hospital Charge Code	2530950
Hospital Revenue Code	250
Min. Negotiated Rate	$497.10
Max. Negotiated Rate	$567.28
Rate for Payer: Cash Price	$380.13
Rate for Payer: Health Management Network Commercial	$497.10
Rate for Payer: Kaiser Permanente Commercial	$526.34
Rate for Payer: MDX Hawaii PPO	$567.28

PP oxycodone/APAP 5/325 mg #3 [HHSC]

Facility

$22.83

Service Code	HCPCS J8499
Hospital Charge Code	2530951
Hospital Revenue Code	253
Min. Negotiated Rate	$11.41
Max. Negotiated Rate	$22.15
Rate for Payer: AlohaCare Medicaid	$11.41
Rate for Payer: AlohaCare Medicare	$11.41
Rate for Payer: Cash Price	$14.84
Rate for Payer: Devoted Health Medicare	$12.56
Rate for Payer: Hawaii Medical Service Association Medicare	$11.41
Rate for Payer: Hawaii Western Management Group Commercial	$21.69
Rate for Payer: Health Management Network Commercial	$19.41
Rate for Payer: Humana Medicare	$11.41
Rate for Payer: Kaiser Permanente Commercial	$20.55
Rate for Payer: Kaiser Permanente Medicaid	$11.64
Rate for Payer: Kaiser Permanente Medicare	$11.41
Rate for Payer: MDX Hawaii PPO	$22.15
Rate for Payer: Ohana Health Plan Medicaid	$11.41
Rate for Payer: Ohana Health Plan Medicare	$11.41
Rate for Payer: UnitedHealthcare Medicare	$11.41
Rate for Payer: University Health Alliance Commercial	$16.64

PP oxycodone/APAP 5/325 mg #3 [HHSC]

Facility

$22.83

Service Code	HCPCS J8499
Hospital Charge Code	2530951
Hospital Revenue Code	250
Min. Negotiated Rate	$19.41
Max. Negotiated Rate	$22.15
Rate for Payer: Cash Price	$14.84
Rate for Payer: Health Management Network Commercial	$19.41
Rate for Payer: Kaiser Permanente Commercial	$20.55
Rate for Payer: MDX Hawaii PPO	$22.15

PP oxycodone/APAP 5/325 mg #6 [HHSC]

Facility

$49.67

Service Code	HCPCS J8499
Hospital Charge Code	2530952
Hospital Revenue Code	253
Min. Negotiated Rate	$24.84
Max. Negotiated Rate	$48.18
Rate for Payer: AlohaCare Medicaid	$24.84
Rate for Payer: AlohaCare Medicare	$24.84
Rate for Payer: Cash Price	$32.29
Rate for Payer: Devoted Health Medicare	$27.32
Rate for Payer: Hawaii Medical Service Association Medicare	$24.84
Rate for Payer: Hawaii Western Management Group Commercial	$47.19
Rate for Payer: Health Management Network Commercial	$42.22
Rate for Payer: Humana Medicare	$24.84
Rate for Payer: Kaiser Permanente Commercial	$44.70
Rate for Payer: Kaiser Permanente Medicaid	$25.33
Rate for Payer: Kaiser Permanente Medicare	$24.84
Rate for Payer: MDX Hawaii PPO	$48.18
Rate for Payer: Ohana Health Plan Medicaid	$24.84
Rate for Payer: Ohana Health Plan Medicare	$24.84
Rate for Payer: UnitedHealthcare Medicare	$24.84
Rate for Payer: University Health Alliance Commercial	$36.20

PP oxycodone/APAP 5/325 mg #6 [HHSC]

Facility

$49.67

Service Code	HCPCS J8499
Hospital Charge Code	2530952
Hospital Revenue Code	250
Min. Negotiated Rate	$42.22
Max. Negotiated Rate	$48.18
Rate for Payer: Cash Price	$32.29
Rate for Payer: Health Management Network Commercial	$42.22
Rate for Payer: Kaiser Permanente Commercial	$44.70
Rate for Payer: MDX Hawaii PPO	$48.18

PP oxymetazoline 0.05% nasal 15mL [HHSC]

Facility

$33.08

Service Code	HCPCS A9150
Hospital Charge Code	2530996
Hospital Revenue Code	253
Min. Negotiated Rate	$16.54
Max. Negotiated Rate	$32.09
Rate for Payer: AlohaCare Medicaid	$16.54
Rate for Payer: AlohaCare Medicaid	$13.98
Rate for Payer: AlohaCare Medicare	$13.98
Rate for Payer: AlohaCare Medicare	$16.54
Rate for Payer: Cash Price	$18.17
Rate for Payer: Cash Price	$21.50
Rate for Payer: Devoted Health Medicare	$18.19
Rate for Payer: Devoted Health Medicare	$15.38
Rate for Payer: Hawaii Medical Service Association Medicare	$13.98
Rate for Payer: Hawaii Medical Service Association Medicare	$16.54
Rate for Payer: Hawaii Western Management Group Commercial	$26.56
Rate for Payer: Hawaii Western Management Group Commercial	$31.43
Rate for Payer: Health Management Network Commercial	$28.12
Rate for Payer: Health Management Network Commercial	$23.77
Rate for Payer: Humana Medicare	$16.54
Rate for Payer: Humana Medicare	$13.98
Rate for Payer: Kaiser Permanente Commercial	$25.16
Rate for Payer: Kaiser Permanente Commercial	$29.77
Rate for Payer: Kaiser Permanente Medicaid	$16.87
Rate for Payer: Kaiser Permanente Medicaid	$14.26
Rate for Payer: Kaiser Permanente Medicare	$13.98
Rate for Payer: Kaiser Permanente Medicare	$16.54
Rate for Payer: MDX Hawaii PPO	$27.12
Rate for Payer: MDX Hawaii PPO	$32.09
Rate for Payer: Ohana Health Plan Medicaid	$13.98
Rate for Payer: Ohana Health Plan Medicaid	$16.54
Rate for Payer: Ohana Health Plan Medicare	$13.98
Rate for Payer: Ohana Health Plan Medicare	$16.54
Rate for Payer: UnitedHealthcare Medicare	$16.54
Rate for Payer: UnitedHealthcare Medicare	$13.98
Rate for Payer: University Health Alliance Commercial	$24.11
Rate for Payer: University Health Alliance Commercial	$20.38

PP oxymetazoline 0.05% nasal 15mL [HHSC]

Facility

$27.96

Service Code	HCPCS A9150
Hospital Charge Code	2530996
Hospital Revenue Code	250
Min. Negotiated Rate	$23.77
Max. Negotiated Rate	$27.12
Rate for Payer: Cash Price	$18.17
Rate for Payer: Cash Price	$21.50
Rate for Payer: Health Management Network Commercial	$23.77
Rate for Payer: Health Management Network Commercial	$28.12
Rate for Payer: Kaiser Permanente Commercial	$25.16
Rate for Payer: Kaiser Permanente Commercial	$29.77
Rate for Payer: MDX Hawaii PPO	$32.09
Rate for Payer: MDX Hawaii PPO	$27.12

PP penicillin VK 500 mg tab #4 [HHSC]

Facility

$25.94

Service Code	HCPCS J8499
Hospital Charge Code	2530954
Hospital Revenue Code	253
Min. Negotiated Rate	$12.97
Max. Negotiated Rate	$25.16
Rate for Payer: AlohaCare Medicaid	$12.97
Rate for Payer: AlohaCare Medicare	$12.97
Rate for Payer: Cash Price	$16.86
Rate for Payer: Devoted Health Medicare	$14.27
Rate for Payer: Hawaii Medical Service Association Medicare	$12.97
Rate for Payer: Hawaii Western Management Group Commercial	$24.64
Rate for Payer: Health Management Network Commercial	$22.05
Rate for Payer: Humana Medicare	$12.97
Rate for Payer: Kaiser Permanente Commercial	$23.35
Rate for Payer: Kaiser Permanente Medicaid	$13.23
Rate for Payer: Kaiser Permanente Medicare	$12.97
Rate for Payer: MDX Hawaii PPO	$25.16
Rate for Payer: Ohana Health Plan Medicaid	$12.97
Rate for Payer: Ohana Health Plan Medicare	$12.97
Rate for Payer: UnitedHealthcare Medicare	$12.97
Rate for Payer: University Health Alliance Commercial	$18.91

PP penicillin VK 500 mg tab #4 [HHSC]

Facility

$25.94

Service Code	HCPCS J8499
Hospital Charge Code	2530954
Hospital Revenue Code	250
Min. Negotiated Rate	$22.05
Max. Negotiated Rate	$25.16
Rate for Payer: Cash Price	$16.86
Rate for Payer: Health Management Network Commercial	$22.05
Rate for Payer: Kaiser Permanente Commercial	$23.35
Rate for Payer: MDX Hawaii PPO	$25.16

PP phenazopyrid 200mg tab #3 [HHSC]

Facility

$68.31

Service Code	HCPCS J8499
Hospital Charge Code	2530955
Hospital Revenue Code	253
Min. Negotiated Rate	$34.16
Max. Negotiated Rate	$66.26
Rate for Payer: AlohaCare Medicaid	$34.16
Rate for Payer: AlohaCare Medicare	$34.16
Rate for Payer: Cash Price	$44.40
Rate for Payer: Devoted Health Medicare	$37.57
Rate for Payer: Hawaii Medical Service Association Medicare	$34.16
Rate for Payer: Hawaii Western Management Group Commercial	$64.89
Rate for Payer: Health Management Network Commercial	$58.06
Rate for Payer: Humana Medicare	$34.16
Rate for Payer: Kaiser Permanente Commercial	$61.48
Rate for Payer: Kaiser Permanente Medicaid	$34.84
Rate for Payer: Kaiser Permanente Medicare	$34.16
Rate for Payer: MDX Hawaii PPO	$66.26
Rate for Payer: Ohana Health Plan Medicaid	$34.16
Rate for Payer: Ohana Health Plan Medicare	$34.16
Rate for Payer: UnitedHealthcare Medicare	$34.16
Rate for Payer: University Health Alliance Commercial	$49.79

PP phenazopyrid 200mg tab #3 [HHSC]

Facility

$68.31

Service Code	HCPCS J8499
Hospital Charge Code	2530955
Hospital Revenue Code	250
Min. Negotiated Rate	$58.06
Max. Negotiated Rate	$66.26
Rate for Payer: Cash Price	$44.40
Rate for Payer: Health Management Network Commercial	$58.06
Rate for Payer: Kaiser Permanente Commercial	$61.48
Rate for Payer: MDX Hawaii PPO	$66.26

PP prednisoLONE 15mg/5mL 60mL [HHSC]

Facility

$96.46

Service Code	HCPCS J8499
Hospital Charge Code	2530956
Hospital Revenue Code	250
Min. Negotiated Rate	$81.99
Max. Negotiated Rate	$93.57
Rate for Payer: Cash Price	$62.70
Rate for Payer: Health Management Network Commercial	$81.99
Rate for Payer: Kaiser Permanente Commercial	$86.81
Rate for Payer: MDX Hawaii PPO	$93.57

PP prednisoLONE 15mg/5mL 60mL [HHSC]

Facility

$96.46

Service Code	HCPCS J8499
Hospital Charge Code	2530956
Hospital Revenue Code	253
Min. Negotiated Rate	$48.23
Max. Negotiated Rate	$93.57
Rate for Payer: AlohaCare Medicaid	$48.23
Rate for Payer: AlohaCare Medicare	$48.23
Rate for Payer: Cash Price	$62.70
Rate for Payer: Devoted Health Medicare	$53.05
Rate for Payer: Hawaii Medical Service Association Medicare	$48.23
Rate for Payer: Hawaii Western Management Group Commercial	$91.64
Rate for Payer: Health Management Network Commercial	$81.99
Rate for Payer: Humana Medicare	$48.23
Rate for Payer: Kaiser Permanente Commercial	$86.81
Rate for Payer: Kaiser Permanente Medicaid	$49.19
Rate for Payer: Kaiser Permanente Medicare	$48.23
Rate for Payer: MDX Hawaii PPO	$93.57
Rate for Payer: Ohana Health Plan Medicaid	$48.23
Rate for Payer: Ohana Health Plan Medicare	$48.23
Rate for Payer: UnitedHealthcare Medicare	$48.23
Rate for Payer: University Health Alliance Commercial	$70.31

PP prednisone 20 mg tab #3 [HHSC]

Facility

$4.75

Service Code	HCPCS J8499
Hospital Charge Code	2530957
Hospital Revenue Code	253
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$4.61
Rate for Payer: AlohaCare Medicaid	$2.38
Rate for Payer: AlohaCare Medicaid	$2.06
Rate for Payer: AlohaCare Medicaid	$2.16
Rate for Payer: AlohaCare Medicare	$2.06
Rate for Payer: AlohaCare Medicare	$2.38
Rate for Payer: AlohaCare Medicare	$2.16
Rate for Payer: Cash Price	$2.81
Rate for Payer: Cash Price	$2.68
Rate for Payer: Cash Price	$3.09
Rate for Payer: Devoted Health Medicare	$2.38
Rate for Payer: Devoted Health Medicare	$2.27
Rate for Payer: Devoted Health Medicare	$2.61
Rate for Payer: Hawaii Medical Service Association Medicare	$2.06
Rate for Payer: Hawaii Medical Service Association Medicare	$2.16
Rate for Payer: Hawaii Medical Service Association Medicare	$2.38
Rate for Payer: Hawaii Western Management Group Commercial	$4.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.51
Rate for Payer: Hawaii Western Management Group Commercial	$3.91
Rate for Payer: Health Management Network Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$4.04
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Humana Medicare	$2.06
Rate for Payer: Humana Medicare	$2.16
Rate for Payer: Humana Medicare	$2.38
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: Kaiser Permanente Commercial	$3.71
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: Kaiser Permanente Medicaid	$2.10
Rate for Payer: Kaiser Permanente Medicaid	$2.42
Rate for Payer: Kaiser Permanente Medicaid	$2.20
Rate for Payer: Kaiser Permanente Medicare	$2.06
Rate for Payer: Kaiser Permanente Medicare	$2.38
Rate for Payer: Kaiser Permanente Medicare	$2.16
Rate for Payer: MDX Hawaii PPO	$4.61
Rate for Payer: MDX Hawaii PPO	$4.19
Rate for Payer: MDX Hawaii PPO	$4.00
Rate for Payer: Ohana Health Plan Medicaid	$2.06
Rate for Payer: Ohana Health Plan Medicaid	$2.16
Rate for Payer: Ohana Health Plan Medicaid	$2.38
Rate for Payer: Ohana Health Plan Medicare	$2.06
Rate for Payer: Ohana Health Plan Medicare	$2.16
Rate for Payer: Ohana Health Plan Medicare	$2.38
Rate for Payer: UnitedHealthcare Medicare	$2.16
Rate for Payer: UnitedHealthcare Medicare	$2.38
Rate for Payer: UnitedHealthcare Medicare	$2.06
Rate for Payer: University Health Alliance Commercial	$3.46
Rate for Payer: University Health Alliance Commercial	$3.00
Rate for Payer: University Health Alliance Commercial	$3.15

PP prednisone 20 mg tab #3 [HHSC]

Facility

$4.75

Service Code	HCPCS J8499
Hospital Charge Code	2530957
Hospital Revenue Code	250
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$4.61
Rate for Payer: Cash Price	$3.09
Rate for Payer: Cash Price	$2.81
Rate for Payer: Cash Price	$2.68
Rate for Payer: Health Management Network Commercial	$4.04
Rate for Payer: Health Management Network Commercial	$3.50
Rate for Payer: Health Management Network Commercial	$3.67
Rate for Payer: Kaiser Permanente Commercial	$3.89
Rate for Payer: Kaiser Permanente Commercial	$3.71
Rate for Payer: Kaiser Permanente Commercial	$4.28
Rate for Payer: MDX Hawaii PPO	$4.19
Rate for Payer: MDX Hawaii PPO	$4.00
Rate for Payer: MDX Hawaii PPO	$4.61

PP promethazine 25 mg tab #3 [HHSC]

Facility

$8.45

Service Code	HCPCS J8499
Hospital Charge Code	2530960
Hospital Revenue Code	253
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$8.20
Rate for Payer: AlohaCare Medicaid	$4.22
Rate for Payer: AlohaCare Medicaid	$4.51
Rate for Payer: AlohaCare Medicare	$4.22
Rate for Payer: AlohaCare Medicare	$4.51
Rate for Payer: Cash Price	$5.87
Rate for Payer: Cash Price	$5.49
Rate for Payer: Devoted Health Medicare	$4.65
Rate for Payer: Devoted Health Medicare	$4.97
Rate for Payer: Hawaii Medical Service Association Medicare	$4.51
Rate for Payer: Hawaii Medical Service Association Medicare	$4.22
Rate for Payer: Hawaii Western Management Group Commercial	$8.58
Rate for Payer: Hawaii Western Management Group Commercial	$8.03
Rate for Payer: Health Management Network Commercial	$7.18
Rate for Payer: Health Management Network Commercial	$7.68
Rate for Payer: Humana Medicare	$4.51
Rate for Payer: Humana Medicare	$4.22
Rate for Payer: Kaiser Permanente Commercial	$7.61
Rate for Payer: Kaiser Permanente Commercial	$8.13
Rate for Payer: Kaiser Permanente Medicaid	$4.61
Rate for Payer: Kaiser Permanente Medicaid	$4.31
Rate for Payer: Kaiser Permanente Medicare	$4.51
Rate for Payer: Kaiser Permanente Medicare	$4.22
Rate for Payer: MDX Hawaii PPO	$8.76
Rate for Payer: MDX Hawaii PPO	$8.20
Rate for Payer: Ohana Health Plan Medicaid	$4.22
Rate for Payer: Ohana Health Plan Medicaid	$4.51
Rate for Payer: Ohana Health Plan Medicare	$4.22
Rate for Payer: Ohana Health Plan Medicare	$4.51
Rate for Payer: UnitedHealthcare Medicare	$4.22
Rate for Payer: UnitedHealthcare Medicare	$4.51
Rate for Payer: University Health Alliance Commercial	$6.58
Rate for Payer: University Health Alliance Commercial	$6.16

PP promethazine 25 mg tab #3 [HHSC]

Facility

$9.03

Service Code	HCPCS J8499
Hospital Charge Code	2530960
Hospital Revenue Code	250
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$8.76
Rate for Payer: Cash Price	$5.87
Rate for Payer: Cash Price	$5.49
Rate for Payer: Health Management Network Commercial	$7.68
Rate for Payer: Health Management Network Commercial	$7.18
Rate for Payer: Kaiser Permanente Commercial	$8.13
Rate for Payer: Kaiser Permanente Commercial	$7.61
Rate for Payer: MDX Hawaii PPO	$8.20
Rate for Payer: MDX Hawaii PPO	$8.76

PP prometh-cod 6.25-10 mg/5 mL 60 mL [HHSC]

Facility

$23.23

Service Code	HCPCS J8499
Hospital Charge Code	2531121
Hospital Revenue Code	253
Min. Negotiated Rate	$11.62
Max. Negotiated Rate	$22.53
Rate for Payer: AlohaCare Medicaid	$11.62
Rate for Payer: AlohaCare Medicaid	$23.36
Rate for Payer: AlohaCare Medicare	$11.62
Rate for Payer: AlohaCare Medicare	$23.36
Rate for Payer: Cash Price	$30.36
Rate for Payer: Cash Price	$15.10
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Devoted Health Medicare	$25.69
Rate for Payer: Hawaii Medical Service Association Medicare	$23.36
Rate for Payer: Hawaii Medical Service Association Medicare	$11.62
Rate for Payer: Hawaii Western Management Group Commercial	$44.37
Rate for Payer: Hawaii Western Management Group Commercial	$22.07
Rate for Payer: Health Management Network Commercial	$19.75
Rate for Payer: Health Management Network Commercial	$39.70
Rate for Payer: Humana Medicare	$23.36
Rate for Payer: Humana Medicare	$11.62
Rate for Payer: Kaiser Permanente Commercial	$20.91
Rate for Payer: Kaiser Permanente Commercial	$42.04
Rate for Payer: Kaiser Permanente Medicaid	$23.82
Rate for Payer: Kaiser Permanente Medicaid	$11.85
Rate for Payer: Kaiser Permanente Medicare	$23.36
Rate for Payer: Kaiser Permanente Medicare	$11.62
Rate for Payer: MDX Hawaii PPO	$45.31
Rate for Payer: MDX Hawaii PPO	$22.53
Rate for Payer: Ohana Health Plan Medicaid	$11.62
Rate for Payer: Ohana Health Plan Medicaid	$23.36
Rate for Payer: Ohana Health Plan Medicare	$11.62
Rate for Payer: Ohana Health Plan Medicare	$23.36
Rate for Payer: UnitedHealthcare Medicare	$11.62
Rate for Payer: UnitedHealthcare Medicare	$23.36
Rate for Payer: University Health Alliance Commercial	$34.05
Rate for Payer: University Health Alliance Commercial	$16.93

PP prometh-cod 6.25-10 mg/5 mL 60 mL [HHSC]

Facility

$46.71

Service Code	HCPCS J8499
Hospital Charge Code	2531121
Hospital Revenue Code	250
Min. Negotiated Rate	$39.70
Max. Negotiated Rate	$45.31
Rate for Payer: Cash Price	$30.36
Rate for Payer: Cash Price	$15.10
Rate for Payer: Health Management Network Commercial	$39.70
Rate for Payer: Health Management Network Commercial	$19.75
Rate for Payer: Kaiser Permanente Commercial	$42.04
Rate for Payer: Kaiser Permanente Commercial	$20.91
Rate for Payer: MDX Hawaii PPO	$22.53
Rate for Payer: MDX Hawaii PPO	$45.31

PP raltegravir 400 mg tab #2 [HHSC]

Facility

$390.41

Service Code	HCPCS J8499
Hospital Charge Code	2531072
Hospital Revenue Code	250
Min. Negotiated Rate	$331.85
Max. Negotiated Rate	$378.70
Rate for Payer: Cash Price	$253.77
Rate for Payer: Health Management Network Commercial	$331.85
Rate for Payer: Kaiser Permanente Commercial	$351.37
Rate for Payer: MDX Hawaii PPO	$378.70

PP raltegravir 400 mg tab #2 [HHSC]

Facility

$390.41

Service Code	HCPCS J8499
Hospital Charge Code	2531072
Hospital Revenue Code	253
Min. Negotiated Rate	$195.21
Max. Negotiated Rate	$378.70
Rate for Payer: AlohaCare Medicaid	$195.21
Rate for Payer: AlohaCare Medicare	$195.21
Rate for Payer: Cash Price	$253.77
Rate for Payer: Devoted Health Medicare	$214.73
Rate for Payer: Hawaii Medical Service Association Medicare	$195.21
Rate for Payer: Hawaii Western Management Group Commercial	$370.89
Rate for Payer: Health Management Network Commercial	$331.85
Rate for Payer: Humana Medicare	$195.21
Rate for Payer: Kaiser Permanente Commercial	$351.37
Rate for Payer: Kaiser Permanente Medicaid	$199.11
Rate for Payer: Kaiser Permanente Medicare	$195.21
Rate for Payer: MDX Hawaii PPO	$378.70
Rate for Payer: Ohana Health Plan Medicaid	$195.21
Rate for Payer: Ohana Health Plan Medicare	$195.21
Rate for Payer: UnitedHealthcare Medicare	$195.21
Rate for Payer: University Health Alliance Commercial	$284.57

PP silver sulfaDIAZINE 1% 25gm [HHSC]

Facility

$53.85

Service Code	HCPCS A9270
Hospital Charge Code	2530964
Hospital Revenue Code	250
Min. Negotiated Rate	$45.77
Max. Negotiated Rate	$52.23
Rate for Payer: Cash Price	$35.00
Rate for Payer: Health Management Network Commercial	$45.77
Rate for Payer: Kaiser Permanente Commercial	$48.47
Rate for Payer: MDX Hawaii PPO	$52.23

Know your out-of-pocket cost for care.

All Charges