|
allopurinol 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687067701
|
| Hospital Charge Code |
2500035
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
allopurinol 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62584098801
|
| Hospital Charge Code |
2500035
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
allopurinol 100 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62584098801
|
| Hospital Charge Code |
2500035
|
|
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
|
|
|
allopurinol 100 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079020520
|
| Hospital Charge Code |
2500035
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
allopurinol 300 mg tablet [HHSC]
|
Facility
|
IP
|
$5.24
|
|
|
Service Code
|
NDC 60687068801
|
| Hospital Charge Code |
2500036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$5.08 |
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Health Management Network Commercial |
$4.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.72
|
| Rate for Payer: MDX Hawaii PPO |
$5.08
|
|
|
allopurinol 300 mg tablet [HHSC]
|
Facility
|
OP
|
$5.24
|
|
|
Service Code
|
NDC 60687068801
|
| Hospital Charge Code |
2500036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$5.08 |
| Rate for Payer: AlohaCare Medicaid |
$2.62
|
| Rate for Payer: AlohaCare Medicare |
$2.62
|
| Rate for Payer: Cash Price |
$3.41
|
| Rate for Payer: Devoted Health Medicare |
$2.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.98
|
| Rate for Payer: Health Management Network Commercial |
$4.45
|
| Rate for Payer: Humana Medicare |
$2.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.62
|
| Rate for Payer: MDX Hawaii PPO |
$5.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.62
|
| Rate for Payer: University Health Alliance Commercial |
$3.82
|
|
|
allopurinol 300 mg tablet [HHSC]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 62584071301
|
| Hospital Charge Code |
2500036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: AlohaCare Medicaid |
$1.96
|
| Rate for Payer: AlohaCare Medicare |
$1.96
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Devoted Health Medicare |
$2.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.72
|
| Rate for Payer: Health Management Network Commercial |
$3.33
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.96
|
| Rate for Payer: MDX Hawaii PPO |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.96
|
| Rate for Payer: University Health Alliance Commercial |
$2.86
|
|
|
allopurinol 300 mg tablet [HHSC]
|
Facility
|
OP
|
$4.21
|
|
|
Service Code
|
NDC 51079020620
|
| Hospital Charge Code |
2500036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: AlohaCare Medicaid |
$2.10
|
| Rate for Payer: AlohaCare Medicare |
$2.10
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Devoted Health Medicare |
$2.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.00
|
| Rate for Payer: Health Management Network Commercial |
$3.58
|
| Rate for Payer: Humana Medicare |
$2.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.10
|
| Rate for Payer: MDX Hawaii PPO |
$4.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.10
|
| Rate for Payer: University Health Alliance Commercial |
$3.07
|
|
|
allopurinol 300 mg tablet [HHSC]
|
Facility
|
IP
|
$4.21
|
|
|
Service Code
|
NDC 51079020620
|
| Hospital Charge Code |
2500036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: Health Management Network Commercial |
$3.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.79
|
| Rate for Payer: MDX Hawaii PPO |
$4.08
|
|
|
allopurinol 300 mg tablet [HHSC]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 62584071301
|
| Hospital Charge Code |
2500036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$3.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.53
|
| Rate for Payer: MDX Hawaii PPO |
$3.80
|
|
|
Alpha 1 Antitrypsin
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
HCPCS 82103
|
| Hospital Charge Code |
9552422
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$270.63 |
| Rate for Payer: AlohaCare Medicaid |
$139.50
|
| Rate for Payer: AlohaCare Medicare |
$139.50
|
| Rate for Payer: Cash Price |
$181.35
|
| Rate for Payer: Cash Price |
$181.35
|
| Rate for Payer: Devoted Health Medicare |
$153.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.44
|
| Rate for Payer: Health Management Network Commercial |
$237.15
|
| Rate for Payer: Humana Medicare |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$251.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$142.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$270.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.50
|
| Rate for Payer: University Health Alliance Commercial |
$34.72
|
|
|
Alpha 1 Antitrypsin
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
HCPCS 82103
|
| Hospital Charge Code |
9552422
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$237.15 |
| Max. Negotiated Rate |
$270.63 |
| Rate for Payer: Cash Price |
$181.35
|
| Rate for Payer: Health Management Network Commercial |
$237.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$251.10
|
| Rate for Payer: MDX Hawaii PPO |
$270.63
|
|
|
alprostadil ped 500mcg/ml ampule [HHSC]
|
Facility
|
OP
|
$608.89
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
2500039
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$304.44 |
| Max. Negotiated Rate |
$590.62 |
| Rate for Payer: AlohaCare Medicaid |
$304.44
|
| Rate for Payer: AlohaCare Medicare |
$304.44
|
| Rate for Payer: Cash Price |
$395.78
|
| Rate for Payer: Devoted Health Medicare |
$334.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$304.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$578.45
|
| Rate for Payer: Health Management Network Commercial |
$517.56
|
| Rate for Payer: Humana Medicare |
$304.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$548.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$310.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$304.44
|
| Rate for Payer: MDX Hawaii PPO |
$590.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$304.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$304.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$304.44
|
| Rate for Payer: University Health Alliance Commercial |
$443.82
|
|
|
alprostadil ped 500mcg/ml ampule [HHSC]
|
Facility
|
IP
|
$608.89
|
|
|
Service Code
|
HCPCS J0270
|
| Hospital Charge Code |
2500039
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$517.56 |
| Max. Negotiated Rate |
$590.62 |
| Rate for Payer: Cash Price |
$395.78
|
| Rate for Payer: Health Management Network Commercial |
$517.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$548.00
|
| Rate for Payer: MDX Hawaii PPO |
$590.62
|
|
|
alteplase 2 mg vial [HHSC]
|
Facility
|
IP
|
$604.03
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
2500041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$513.43 |
| Max. Negotiated Rate |
$585.91 |
| Rate for Payer: Cash Price |
$392.62
|
| Rate for Payer: Health Management Network Commercial |
$513.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.63
|
| Rate for Payer: MDX Hawaii PPO |
$585.91
|
|
|
alteplase 2 mg vial [HHSC]
|
Facility
|
OP
|
$604.03
|
|
|
Service Code
|
HCPCS J2997
|
| Hospital Charge Code |
2500041
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$585.91 |
| Rate for Payer: AlohaCare Medicaid |
$302.01
|
| Rate for Payer: AlohaCare Medicare |
$302.01
|
| Rate for Payer: Cash Price |
$392.62
|
| Rate for Payer: Cash Price |
$392.62
|
| Rate for Payer: Devoted Health Medicare |
$332.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$94.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$302.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$94.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$573.83
|
| Rate for Payer: Health Management Network Commercial |
$513.43
|
| Rate for Payer: Humana Medicare |
$302.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$543.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$308.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$302.01
|
| Rate for Payer: MDX Hawaii PPO |
$585.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$302.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$302.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$362.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$302.01
|
| Rate for Payer: University Health Alliance Commercial |
$440.28
|
|
|
ALT (SGPT) FSI
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS 84460
|
| Hospital Charge Code |
8117837
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.30 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicare |
$52.50
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Devoted Health Medicare |
$57.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.30
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Humana Medicare |
$52.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.50
|
| Rate for Payer: University Health Alliance Commercial |
$13.69
|
|
|
ALT (SGPT) FSI
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS 84460
|
| Hospital Charge Code |
8117837
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: Cash Price |
$68.25
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
IP
|
$21.17
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.99 |
| Max. Negotiated Rate |
$20.53 |
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: Health Management Network Commercial |
$17.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.05
|
| Rate for Payer: MDX Hawaii PPO |
$20.53
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
IP
|
$21.97
|
|
|
Service Code
|
NDC 66689006099
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.67 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.77
|
| Rate for Payer: MDX Hawaii PPO |
$21.31
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
OP
|
$21.09
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: AlohaCare Medicaid |
$10.54
|
| Rate for Payer: AlohaCare Medicare |
$10.54
|
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: Devoted Health Medicare |
$11.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.04
|
| Rate for Payer: Health Management Network Commercial |
$17.93
|
| Rate for Payer: Humana Medicare |
$10.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.54
|
| Rate for Payer: MDX Hawaii PPO |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.54
|
| Rate for Payer: University Health Alliance Commercial |
$15.37
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
OP
|
$21.17
|
|
|
Service Code
|
NDC 57237031631
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.59 |
| Max. Negotiated Rate |
$20.53 |
| Rate for Payer: AlohaCare Medicaid |
$10.59
|
| Rate for Payer: AlohaCare Medicare |
$10.59
|
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: Devoted Health Medicare |
$11.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.11
|
| Rate for Payer: Health Management Network Commercial |
$17.99
|
| Rate for Payer: Humana Medicare |
$10.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.59
|
| Rate for Payer: MDX Hawaii PPO |
$20.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.59
|
| Rate for Payer: University Health Alliance Commercial |
$15.43
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
OP
|
$21.97
|
|
|
Service Code
|
NDC 66689006099
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.98 |
| Max. Negotiated Rate |
$21.31 |
| Rate for Payer: AlohaCare Medicaid |
$10.98
|
| Rate for Payer: AlohaCare Medicare |
$10.98
|
| Rate for Payer: Cash Price |
$14.28
|
| Rate for Payer: Devoted Health Medicare |
$12.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.87
|
| Rate for Payer: Health Management Network Commercial |
$18.67
|
| Rate for Payer: Humana Medicare |
$10.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.98
|
| Rate for Payer: MDX Hawaii PPO |
$21.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.98
|
| Rate for Payer: University Health Alliance Commercial |
$16.01
|
|
|
alum-mag-sime 200 mg-200 mg-20 mg/5 ml 30 mL [HHSC]
|
Facility
|
IP
|
$21.09
|
|
|
Service Code
|
NDC 00121176130
|
| Hospital Charge Code |
2500027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$20.46 |
| Rate for Payer: Cash Price |
$13.71
|
| Rate for Payer: Health Management Network Commercial |
$17.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.98
|
| Rate for Payer: MDX Hawaii PPO |
$20.46
|
|
|
amino acids 4.25%-D10 (PPN) 1000 mL [HHSC]
|
Facility
|
OP
|
$192.71
|
|
|
Service Code
|
NDC 00338113403
|
| Hospital Charge Code |
2500043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.36 |
| Max. Negotiated Rate |
$186.93 |
| Rate for Payer: AlohaCare Medicaid |
$96.36
|
| Rate for Payer: AlohaCare Medicare |
$96.36
|
| Rate for Payer: Cash Price |
$125.26
|
| Rate for Payer: Devoted Health Medicare |
$105.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$183.07
|
| Rate for Payer: Health Management Network Commercial |
$163.80
|
| Rate for Payer: Humana Medicare |
$96.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$173.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.36
|
| Rate for Payer: MDX Hawaii PPO |
$186.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$96.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$115.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.36
|
| Rate for Payer: University Health Alliance Commercial |
$140.47
|
|
