|
acetaZOLAMIDE 250 mg tablet [HHSC]
|
Facility
|
OP
|
$23.29
|
|
|
Service Code
|
NDC 68084054101
|
| Hospital Charge Code |
2500013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.64 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: AlohaCare Medicaid |
$11.64
|
| Rate for Payer: AlohaCare Medicare |
$11.64
|
| Rate for Payer: Cash Price |
$15.14
|
| Rate for Payer: Devoted Health Medicare |
$12.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.13
|
| Rate for Payer: Health Management Network Commercial |
$19.80
|
| Rate for Payer: Humana Medicare |
$11.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$22.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$16.98
|
|
|
acetaZOLAMIDE 250 mg tablet [HHSC]
|
Facility
|
IP
|
$23.29
|
|
|
Service Code
|
NDC 68084054101
|
| Hospital Charge Code |
2500013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Cash Price |
$15.14
|
| Rate for Payer: Health Management Network Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.96
|
| Rate for Payer: MDX Hawaii PPO |
$22.59
|
|
|
acetaZOLAMIDE 250 mg tablet [HHSC]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 70756072111
|
| Hospital Charge Code |
2500013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Health Management Network Commercial |
$13.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.81
|
| Rate for Payer: MDX Hawaii PPO |
$14.89
|
|
|
acetaZOLAMIDE 250 mg tablet [HHSC]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 70756072111
|
| Hospital Charge Code |
2500013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.67 |
| Max. Negotiated Rate |
$14.89 |
| Rate for Payer: AlohaCare Medicaid |
$7.67
|
| Rate for Payer: AlohaCare Medicare |
$7.67
|
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Devoted Health Medicare |
$8.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.58
|
| Rate for Payer: Health Management Network Commercial |
$13.05
|
| Rate for Payer: Humana Medicare |
$7.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.67
|
| Rate for Payer: MDX Hawaii PPO |
$14.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.67
|
| Rate for Payer: University Health Alliance Commercial |
$11.19
|
|
|
acetaZOLAMIDE 500 mg vial [HHSC]
|
Facility
|
OP
|
$226.31
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
2500015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.23 |
| Max. Negotiated Rate |
$219.52 |
| Rate for Payer: AlohaCare Medicaid |
$113.16
|
| Rate for Payer: AlohaCare Medicaid |
$142.00
|
| Rate for Payer: AlohaCare Medicaid |
$109.39
|
| Rate for Payer: AlohaCare Medicaid |
$108.64
|
| Rate for Payer: AlohaCare Medicare |
$108.64
|
| Rate for Payer: AlohaCare Medicare |
$109.39
|
| Rate for Payer: AlohaCare Medicare |
$113.16
|
| Rate for Payer: AlohaCare Medicare |
$142.00
|
| Rate for Payer: Cash Price |
$141.24
|
| Rate for Payer: Cash Price |
$147.10
|
| Rate for Payer: Cash Price |
$142.21
|
| Rate for Payer: Cash Price |
$142.21
|
| Rate for Payer: Cash Price |
$147.10
|
| Rate for Payer: Cash Price |
$184.60
|
| Rate for Payer: Cash Price |
$141.24
|
| Rate for Payer: Cash Price |
$184.60
|
| Rate for Payer: Devoted Health Medicare |
$120.33
|
| Rate for Payer: Devoted Health Medicare |
$124.47
|
| Rate for Payer: Devoted Health Medicare |
$119.51
|
| Rate for Payer: Devoted Health Medicare |
$156.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$142.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$108.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$113.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$214.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$206.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Health Management Network Commercial |
$185.97
|
| Rate for Payer: Health Management Network Commercial |
$184.70
|
| Rate for Payer: Health Management Network Commercial |
$192.36
|
| Rate for Payer: Humana Medicare |
$109.39
|
| Rate for Payer: Humana Medicare |
$108.64
|
| Rate for Payer: Humana Medicare |
$113.16
|
| Rate for Payer: Humana Medicare |
$142.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$195.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$110.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$142.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$108.64
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: MDX Hawaii PPO |
$219.52
|
| Rate for Payer: MDX Hawaii PPO |
$212.23
|
| Rate for Payer: MDX Hawaii PPO |
$210.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$108.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$113.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$142.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$108.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$113.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$142.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$131.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$170.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$130.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$113.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$142.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$108.64
|
| Rate for Payer: University Health Alliance Commercial |
$207.01
|
| Rate for Payer: University Health Alliance Commercial |
$164.96
|
| Rate for Payer: University Health Alliance Commercial |
$158.38
|
| Rate for Payer: University Health Alliance Commercial |
$159.48
|
|
|
acetaZOLAMIDE 500 mg vial [HHSC]
|
Facility
|
IP
|
$218.79
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
2500015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.97 |
| Max. Negotiated Rate |
$212.23 |
| Rate for Payer: Cash Price |
$142.21
|
| Rate for Payer: Cash Price |
$141.24
|
| Rate for Payer: Cash Price |
$184.60
|
| Rate for Payer: Cash Price |
$147.10
|
| Rate for Payer: Health Management Network Commercial |
$184.70
|
| Rate for Payer: Health Management Network Commercial |
$185.97
|
| Rate for Payer: Health Management Network Commercial |
$192.36
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$195.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.91
|
| Rate for Payer: MDX Hawaii PPO |
$210.77
|
| Rate for Payer: MDX Hawaii PPO |
$219.52
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: MDX Hawaii PPO |
$212.23
|
|
|
acetaZOLAMIDE ER 500 mg capsule [HHSC]
|
Facility
|
OP
|
$31.72
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
2500014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.86 |
| Max. Negotiated Rate |
$30.77 |
| Rate for Payer: AlohaCare Medicaid |
$15.86
|
| Rate for Payer: AlohaCare Medicare |
$15.86
|
| Rate for Payer: Cash Price |
$20.62
|
| Rate for Payer: Devoted Health Medicare |
$17.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.13
|
| Rate for Payer: Health Management Network Commercial |
$26.96
|
| Rate for Payer: Humana Medicare |
$15.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.86
|
| Rate for Payer: MDX Hawaii PPO |
$30.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.86
|
| Rate for Payer: University Health Alliance Commercial |
$23.12
|
|
|
acetaZOLAMIDE ER 500 mg capsule [HHSC]
|
Facility
|
IP
|
$31.72
|
|
|
Service Code
|
NDC 60687057821
|
| Hospital Charge Code |
2500014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.96 |
| Max. Negotiated Rate |
$30.77 |
| Rate for Payer: Cash Price |
$20.62
|
| Rate for Payer: Health Management Network Commercial |
$26.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.55
|
| Rate for Payer: MDX Hawaii PPO |
$30.77
|
|
|
acetaZOLAMIDE ER 500 mg capsule [HHSC]
|
Facility
|
OP
|
$23.87
|
|
|
Service Code
|
NDC 42571024301
|
| Hospital Charge Code |
2500014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$23.15 |
| Rate for Payer: AlohaCare Medicaid |
$11.94
|
| Rate for Payer: AlohaCare Medicare |
$11.94
|
| Rate for Payer: Cash Price |
$15.52
|
| Rate for Payer: Devoted Health Medicare |
$13.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.68
|
| Rate for Payer: Health Management Network Commercial |
$20.29
|
| Rate for Payer: Humana Medicare |
$11.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.94
|
| Rate for Payer: MDX Hawaii PPO |
$23.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.94
|
| Rate for Payer: University Health Alliance Commercial |
$17.40
|
|
|
acetaZOLAMIDE ER 500 mg capsule [HHSC]
|
Facility
|
IP
|
$23.87
|
|
|
Service Code
|
NDC 42571024301
|
| Hospital Charge Code |
2500014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.29 |
| Max. Negotiated Rate |
$23.15 |
| Rate for Payer: Cash Price |
$15.52
|
| Rate for Payer: Health Management Network Commercial |
$20.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.48
|
| Rate for Payer: MDX Hawaii PPO |
$23.15
|
|
|
Acetone Qualitative FSI
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 82009
|
| Hospital Charge Code |
8404546
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
Acetone Qualitative FSI
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 82009
|
| Hospital Charge Code |
8404546
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicare |
$27.50
|
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Devoted Health Medicare |
$30.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.25
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.52
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Humana Medicare |
$27.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.50
|
| Rate for Payer: University Health Alliance Commercial |
$11.67
|
|
|
Acetone, Qualitative FSI
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 82009
|
| Hospital Charge Code |
9078871
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
|
|
Acetone, Qualitative FSI
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 82009
|
| Hospital Charge Code |
9078871
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$53.35 |
| Rate for Payer: AlohaCare Medicaid |
$27.50
|
| Rate for Payer: AlohaCare Medicare |
$27.50
|
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Cash Price |
$35.75
|
| Rate for Payer: Devoted Health Medicare |
$30.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.25
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.52
|
| Rate for Payer: Health Management Network Commercial |
$46.75
|
| Rate for Payer: Humana Medicare |
$27.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.50
|
| Rate for Payer: MDX Hawaii PPO |
$53.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.50
|
| Rate for Payer: University Health Alliance Commercial |
$11.67
|
|
|
Acetone, Serum FSI
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
8128106
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
|
Acetone, Serum FSI
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 82010
|
| Hospital Charge Code |
8128106
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.00
|
| Rate for Payer: AlohaCare Medicare |
$60.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Devoted Health Medicare |
$66.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.17
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Humana Medicare |
$60.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.13
|
|
|
Acetylcholine Receptor Binding Antibody FSI
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS 83519
|
| Hospital Charge Code |
8117761
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$130.90 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
|
|
Acetylcholine Receptor Binding Antibody FSI
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS 83519
|
| Hospital Charge Code |
8117761
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: AlohaCare Medicaid |
$77.00
|
| Rate for Payer: AlohaCare Medicare |
$77.00
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Devoted Health Medicare |
$84.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.67
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.40
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Humana Medicare |
$77.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$77.00
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.00
|
| Rate for Payer: University Health Alliance Commercial |
$34.93
|
|
|
acetylcysteine 200mg/ml vial (IV) 30ml [HHSC]
|
Facility
|
OP
|
$713.50
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2500021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$692.10 |
| Rate for Payer: AlohaCare Medicaid |
$356.75
|
| Rate for Payer: AlohaCare Medicaid |
$113.22
|
| Rate for Payer: AlohaCare Medicaid |
$486.75
|
| Rate for Payer: AlohaCare Medicaid |
$166.03
|
| Rate for Payer: AlohaCare Medicaid |
$309.10
|
| Rate for Payer: AlohaCare Medicare |
$113.22
|
| Rate for Payer: AlohaCare Medicare |
$309.10
|
| Rate for Payer: AlohaCare Medicare |
$356.75
|
| Rate for Payer: AlohaCare Medicare |
$166.03
|
| Rate for Payer: AlohaCare Medicare |
$486.75
|
| Rate for Payer: Cash Price |
$463.78
|
| Rate for Payer: Cash Price |
$147.19
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Cash Price |
$463.78
|
| Rate for Payer: Cash Price |
$632.78
|
| Rate for Payer: Cash Price |
$632.78
|
| Rate for Payer: Cash Price |
$147.19
|
| Rate for Payer: Devoted Health Medicare |
$535.42
|
| Rate for Payer: Devoted Health Medicare |
$392.43
|
| Rate for Payer: Devoted Health Medicare |
$182.64
|
| Rate for Payer: Devoted Health Medicare |
$340.01
|
| Rate for Payer: Devoted Health Medicare |
$124.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$486.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$113.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$309.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$166.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$356.75
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$587.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$315.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$924.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$677.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$215.13
|
| Rate for Payer: Health Management Network Commercial |
$606.48
|
| Rate for Payer: Health Management Network Commercial |
$192.48
|
| Rate for Payer: Health Management Network Commercial |
$282.26
|
| Rate for Payer: Health Management Network Commercial |
$525.47
|
| Rate for Payer: Health Management Network Commercial |
$827.48
|
| Rate for Payer: Humana Medicare |
$309.10
|
| Rate for Payer: Humana Medicare |
$166.03
|
| Rate for Payer: Humana Medicare |
$113.22
|
| Rate for Payer: Humana Medicare |
$486.75
|
| Rate for Payer: Humana Medicare |
$356.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$876.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$642.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$298.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$496.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$115.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$315.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$169.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$363.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$486.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$166.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$309.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$356.75
|
| Rate for Payer: MDX Hawaii PPO |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$944.29
|
| Rate for Payer: MDX Hawaii PPO |
$322.11
|
| Rate for Payer: MDX Hawaii PPO |
$599.65
|
| Rate for Payer: MDX Hawaii PPO |
$219.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$309.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$166.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$113.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$486.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$113.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$309.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$356.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$166.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$486.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$199.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$428.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$584.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$370.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$356.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$309.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$166.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$113.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$486.75
|
| Rate for Payer: University Health Alliance Commercial |
$709.58
|
| Rate for Payer: University Health Alliance Commercial |
$242.05
|
| Rate for Payer: University Health Alliance Commercial |
$165.06
|
| Rate for Payer: University Health Alliance Commercial |
$520.07
|
| Rate for Payer: University Health Alliance Commercial |
$450.61
|
|
|
acetylcysteine 200mg/ml vial (IV) 30ml [HHSC]
|
Facility
|
IP
|
$226.45
|
|
|
Service Code
|
HCPCS J0132
|
| Hospital Charge Code |
2500021
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$192.48 |
| Max. Negotiated Rate |
$219.66 |
| Rate for Payer: Cash Price |
$147.19
|
| Rate for Payer: Cash Price |
$401.83
|
| Rate for Payer: Cash Price |
$632.78
|
| Rate for Payer: Cash Price |
$463.78
|
| Rate for Payer: Cash Price |
$215.85
|
| Rate for Payer: Health Management Network Commercial |
$525.47
|
| Rate for Payer: Health Management Network Commercial |
$192.48
|
| Rate for Payer: Health Management Network Commercial |
$282.26
|
| Rate for Payer: Health Management Network Commercial |
$606.48
|
| Rate for Payer: Health Management Network Commercial |
$827.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$556.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$876.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$642.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$203.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$298.86
|
| Rate for Payer: MDX Hawaii PPO |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$599.65
|
| Rate for Payer: MDX Hawaii PPO |
$219.66
|
| Rate for Payer: MDX Hawaii PPO |
$322.11
|
| Rate for Payer: MDX Hawaii PPO |
$944.29
|
|
|
acetylcysteine 20% 30 mL vial [HHSC]
|
Facility
|
OP
|
$122.68
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2500019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$119.00 |
| Rate for Payer: AlohaCare Medicaid |
$61.34
|
| Rate for Payer: AlohaCare Medicaid |
$33.66
|
| Rate for Payer: AlohaCare Medicaid |
$74.31
|
| Rate for Payer: AlohaCare Medicare |
$74.31
|
| Rate for Payer: AlohaCare Medicare |
$61.34
|
| Rate for Payer: AlohaCare Medicare |
$33.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$43.76
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Cash Price |
$43.76
|
| Rate for Payer: Devoted Health Medicare |
$67.47
|
| Rate for Payer: Devoted Health Medicare |
$37.03
|
| Rate for Payer: Devoted Health Medicare |
$81.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.31
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$116.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.96
|
| Rate for Payer: Health Management Network Commercial |
$57.23
|
| Rate for Payer: Health Management Network Commercial |
$104.28
|
| Rate for Payer: Health Management Network Commercial |
$126.33
|
| Rate for Payer: Humana Medicare |
$61.34
|
| Rate for Payer: Humana Medicare |
$74.31
|
| Rate for Payer: Humana Medicare |
$33.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.66
|
| Rate for Payer: MDX Hawaii PPO |
$65.31
|
| Rate for Payer: MDX Hawaii PPO |
$144.16
|
| Rate for Payer: MDX Hawaii PPO |
$119.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$73.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.66
|
| Rate for Payer: University Health Alliance Commercial |
$89.42
|
| Rate for Payer: University Health Alliance Commercial |
$108.33
|
| Rate for Payer: University Health Alliance Commercial |
$49.08
|
|
|
acetylcysteine 20% 30 mL vial [HHSC]
|
Facility
|
IP
|
$67.33
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2500019
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.23 |
| Max. Negotiated Rate |
$65.31 |
| Rate for Payer: Cash Price |
$43.76
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$79.74
|
| Rate for Payer: Health Management Network Commercial |
$104.28
|
| Rate for Payer: Health Management Network Commercial |
$57.23
|
| Rate for Payer: Health Management Network Commercial |
$126.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.41
|
| Rate for Payer: MDX Hawaii PPO |
$144.16
|
| Rate for Payer: MDX Hawaii PPO |
$119.00
|
| Rate for Payer: MDX Hawaii PPO |
$65.31
|
|
|
acetylcysteine 20% 4ml vial [HHSC]
|
Facility
|
IP
|
$80.69
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2500020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.59 |
| Max. Negotiated Rate |
$78.27 |
| Rate for Payer: Cash Price |
$52.45
|
| Rate for Payer: Health Management Network Commercial |
$68.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.62
|
| Rate for Payer: MDX Hawaii PPO |
$78.27
|
|
|
acetylcysteine 20% 4ml vial [HHSC]
|
Facility
|
OP
|
$80.69
|
|
|
Service Code
|
HCPCS J7608
|
| Hospital Charge Code |
2500020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$78.27 |
| Rate for Payer: AlohaCare Medicaid |
$40.34
|
| Rate for Payer: AlohaCare Medicare |
$40.34
|
| Rate for Payer: Cash Price |
$52.45
|
| Rate for Payer: Cash Price |
$52.45
|
| Rate for Payer: Devoted Health Medicare |
$44.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.66
|
| Rate for Payer: Health Management Network Commercial |
$68.59
|
| Rate for Payer: Humana Medicare |
$40.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.34
|
| Rate for Payer: MDX Hawaii PPO |
$78.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.34
|
| Rate for Payer: University Health Alliance Commercial |
$58.81
|
|
|
activated charcoal 25 gm/120ml PEDS [HHSC]
|
Facility
|
IP
|
$87.96
|
|
|
Service Code
|
NDC 00574052174
|
| Hospital Charge Code |
2500169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.77 |
| Max. Negotiated Rate |
$85.32 |
| Rate for Payer: Cash Price |
$57.17
|
| Rate for Payer: Health Management Network Commercial |
$74.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.16
|
| Rate for Payer: MDX Hawaii PPO |
$85.32
|
|
