|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN
|
Facility
|
OP
|
$45.87
|
|
|
Service Code
|
HCPCS J0330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$45.41 |
| Rate for Payer: AlohaCare Medicaid |
$22.93
|
| Rate for Payer: AlohaCare Medicaid |
$30.50
|
| Rate for Payer: AlohaCare Medicare |
$54.91
|
| Rate for Payer: AlohaCare Medicare |
$41.28
|
| Rate for Payer: Cash Price |
$39.66
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$39.66
|
| Rate for Payer: Devoted Health Medicare |
$45.41
|
| Rate for Payer: Devoted Health Medicare |
$60.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.96
|
| Rate for Payer: Health Management Network Commercial |
$51.86
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Humana Medicare |
$41.28
|
| Rate for Payer: Humana Medicare |
$54.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.91
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: MDX Hawaii PPO |
$59.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.91
|
| Rate for Payer: University Health Alliance Commercial |
$33.43
|
| Rate for Payer: University Health Alliance Commercial |
$44.47
|
|
|
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLN
|
Facility
|
IP
|
$45.87
|
|
|
Service Code
|
HCPCS J0330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.99 |
| Max. Negotiated Rate |
$44.49 |
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$39.66
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$51.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.91
|
| Rate for Payer: MDX Hawaii PPO |
$59.18
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 100 MG/5 ML (20 MG/ML) IV SYR
|
Facility
|
IP
|
$121.50
|
|
|
Service Code
|
HCPCS J0330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.28 |
| Max. Negotiated Rate |
$117.86 |
| Rate for Payer: Cash Price |
$78.98
|
| Rate for Payer: Health Management Network Commercial |
$103.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.35
|
| Rate for Payer: MDX Hawaii PPO |
$117.86
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 100 MG/5 ML (20 MG/ML) IV SYR
|
Facility
|
OP
|
$121.50
|
|
|
Service Code
|
HCPCS J0330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: AlohaCare Medicaid |
$60.75
|
| Rate for Payer: AlohaCare Medicare |
$109.35
|
| Rate for Payer: Cash Price |
$78.98
|
| Rate for Payer: Cash Price |
$78.98
|
| Rate for Payer: Devoted Health Medicare |
$120.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$115.42
|
| Rate for Payer: Health Management Network Commercial |
$103.28
|
| Rate for Payer: Humana Medicare |
$109.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.35
|
| Rate for Payer: MDX Hawaii PPO |
$117.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$72.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.35
|
| Rate for Payer: University Health Alliance Commercial |
$88.56
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYR
|
Facility
|
IP
|
$116.12
|
|
|
Service Code
|
HCPCS J0330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$112.64 |
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Health Management Network Commercial |
$98.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.51
|
| Rate for Payer: MDX Hawaii PPO |
$112.64
|
|
|
SUCCINYLCHOLINE-SOD CL,ISO(PF) 200 MG/10 ML (20 MG/ML) IV SYR
|
Facility
|
OP
|
$116.12
|
|
|
Service Code
|
HCPCS J0330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$114.96 |
| Rate for Payer: AlohaCare Medicaid |
$58.06
|
| Rate for Payer: AlohaCare Medicare |
$104.51
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Cash Price |
$75.48
|
| Rate for Payer: Devoted Health Medicare |
$114.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$104.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.31
|
| Rate for Payer: Health Management Network Commercial |
$98.70
|
| Rate for Payer: Humana Medicare |
$104.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$104.51
|
| Rate for Payer: MDX Hawaii PPO |
$112.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$104.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$104.51
|
| Rate for Payer: University Health Alliance Commercial |
$84.64
|
|
|
SUCRALFATE 100 MG/ML PO SUSP
|
Facility
|
IP
|
$67.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.72 |
| Max. Negotiated Rate |
$65.86 |
| Rate for Payer: Cash Price |
$44.14
|
| Rate for Payer: Cash Price |
$40.51
|
| Rate for Payer: Health Management Network Commercial |
$57.72
|
| Rate for Payer: Health Management Network Commercial |
$52.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.09
|
| Rate for Payer: MDX Hawaii PPO |
$60.45
|
| Rate for Payer: MDX Hawaii PPO |
$65.86
|
|
|
SUCRALFATE 100 MG/ML PO SUSP
|
Facility
|
OP
|
$62.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.16 |
| Max. Negotiated Rate |
$61.70 |
| Rate for Payer: AlohaCare Medicaid |
$31.16
|
| Rate for Payer: AlohaCare Medicaid |
$33.95
|
| Rate for Payer: AlohaCare Medicare |
$56.09
|
| Rate for Payer: AlohaCare Medicare |
$61.11
|
| Rate for Payer: Cash Price |
$44.14
|
| Rate for Payer: Cash Price |
$40.51
|
| Rate for Payer: Devoted Health Medicare |
$61.70
|
| Rate for Payer: Devoted Health Medicare |
$67.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.20
|
| Rate for Payer: Health Management Network Commercial |
$52.97
|
| Rate for Payer: Health Management Network Commercial |
$57.72
|
| Rate for Payer: Humana Medicare |
$61.11
|
| Rate for Payer: Humana Medicare |
$56.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.09
|
| Rate for Payer: MDX Hawaii PPO |
$65.86
|
| Rate for Payer: MDX Hawaii PPO |
$60.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.11
|
| Rate for Payer: University Health Alliance Commercial |
$49.49
|
| Rate for Payer: University Health Alliance Commercial |
$45.43
|
|
|
SUCRALFATE 1 GRAM PO TABLET
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: AlohaCare Medicaid |
$1.05
|
| Rate for Payer: AlohaCare Medicaid |
$1.96
|
| Rate for Payer: AlohaCare Medicare |
$1.89
|
| Rate for Payer: AlohaCare Medicare |
$3.53
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Devoted Health Medicare |
$2.08
|
| Rate for Payer: Devoted Health Medicare |
$3.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.00
|
| Rate for Payer: Health Management Network Commercial |
$1.78
|
| Rate for Payer: Health Management Network Commercial |
$3.33
|
| Rate for Payer: Humana Medicare |
$3.53
|
| Rate for Payer: Humana Medicare |
$1.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.89
|
| Rate for Payer: MDX Hawaii PPO |
$3.80
|
| Rate for Payer: MDX Hawaii PPO |
$2.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.53
|
| Rate for Payer: University Health Alliance Commercial |
$2.86
|
| Rate for Payer: University Health Alliance Commercial |
$1.53
|
|
|
SUCRALFATE 1 GRAM PO TABLET
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$3.80 |
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Management Network Commercial |
$3.33
|
| Rate for Payer: Health Management Network Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: MDX Hawaii PPO |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.80
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
|
IP
|
$310.44
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.87 |
| Max. Negotiated Rate |
$301.13 |
| Rate for Payer: Cash Price |
$201.79
|
| Rate for Payer: Health Management Network Commercial |
$263.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.40
|
| Rate for Payer: MDX Hawaii PPO |
$301.13
|
|
|
SULFACETAMIDE SODIUM 10 % OPHT DROP
|
Facility
|
OP
|
$310.44
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.22 |
| Max. Negotiated Rate |
$307.34 |
| Rate for Payer: AlohaCare Medicaid |
$155.22
|
| Rate for Payer: AlohaCare Medicare |
$279.40
|
| Rate for Payer: Cash Price |
$201.79
|
| Rate for Payer: Devoted Health Medicare |
$307.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$279.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$294.92
|
| Rate for Payer: Health Management Network Commercial |
$263.87
|
| Rate for Payer: Humana Medicare |
$279.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$279.40
|
| Rate for Payer: MDX Hawaii PPO |
$301.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$279.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$279.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$279.40
|
| Rate for Payer: University Health Alliance Commercial |
$226.28
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP
|
Facility
|
OP
|
$686.79
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$343.39 |
| Max. Negotiated Rate |
$679.92 |
| Rate for Payer: AlohaCare Medicaid |
$343.39
|
| Rate for Payer: AlohaCare Medicaid |
$13.20
|
| Rate for Payer: AlohaCare Medicare |
$23.75
|
| Rate for Payer: AlohaCare Medicare |
$618.11
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$446.41
|
| Rate for Payer: Devoted Health Medicare |
$679.92
|
| Rate for Payer: Devoted Health Medicare |
$26.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$618.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$652.45
|
| Rate for Payer: Health Management Network Commercial |
$583.77
|
| Rate for Payer: Health Management Network Commercial |
$22.43
|
| Rate for Payer: Humana Medicare |
$618.11
|
| Rate for Payer: Humana Medicare |
$23.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$618.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$350.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$618.11
|
| Rate for Payer: MDX Hawaii PPO |
$25.60
|
| Rate for Payer: MDX Hawaii PPO |
$666.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$618.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$618.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$618.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.75
|
| Rate for Payer: University Health Alliance Commercial |
$500.60
|
| Rate for Payer: University Health Alliance Commercial |
$19.24
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP
|
Facility
|
IP
|
$26.39
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.43 |
| Max. Negotiated Rate |
$25.60 |
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$446.41
|
| Rate for Payer: Health Management Network Commercial |
$22.43
|
| Rate for Payer: Health Management Network Commercial |
$583.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$618.11
|
| Rate for Payer: MDX Hawaii PPO |
$666.19
|
| Rate for Payer: MDX Hawaii PPO |
$25.60
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABLET
|
Facility
|
IP
|
$3.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.13 |
| Max. Negotiated Rate |
$3.57 |
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Health Management Network Commercial |
$3.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.31
|
| Rate for Payer: MDX Hawaii PPO |
$3.57
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABLET
|
Facility
|
OP
|
$3.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$3.64 |
| Rate for Payer: AlohaCare Medicaid |
$1.84
|
| Rate for Payer: AlohaCare Medicare |
$3.31
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Devoted Health Medicare |
$3.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.50
|
| Rate for Payer: Health Management Network Commercial |
$3.13
|
| Rate for Payer: Humana Medicare |
$3.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.31
|
| Rate for Payer: MDX Hawaii PPO |
$3.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.31
|
| Rate for Payer: University Health Alliance Commercial |
$2.68
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABLET
|
Facility
|
IP
|
$1.75
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.57
|
| Rate for Payer: MDX Hawaii PPO |
$1.70
|
|
|
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABLET
|
Facility
|
OP
|
$1.75
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.73 |
| Rate for Payer: AlohaCare Medicaid |
$0.88
|
| Rate for Payer: AlohaCare Medicare |
$1.57
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Devoted Health Medicare |
$1.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.66
|
| Rate for Payer: Health Management Network Commercial |
$1.49
|
| Rate for Payer: Humana Medicare |
$1.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.57
|
| Rate for Payer: MDX Hawaii PPO |
$1.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.57
|
| Rate for Payer: University Health Alliance Commercial |
$1.28
|
|
|
SULFASALAZINE 500 MG PO TABLET
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.38 |
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Health Management Network Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.28
|
| Rate for Payer: MDX Hawaii PPO |
$1.38
|
|
|
SULFASALAZINE 500 MG PO TABLET
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$1.41 |
| Rate for Payer: AlohaCare Medicaid |
$0.71
|
| Rate for Payer: AlohaCare Medicare |
$1.28
|
| Rate for Payer: Cash Price |
$0.92
|
| Rate for Payer: Devoted Health Medicare |
$1.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.35
|
| Rate for Payer: Health Management Network Commercial |
$1.21
|
| Rate for Payer: Humana Medicare |
$1.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.28
|
| Rate for Payer: MDX Hawaii PPO |
$1.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.28
|
| Rate for Payer: University Health Alliance Commercial |
$1.04
|
|
|
SUMATRIPTAN SUCCINATE 25 MG PO TABLET
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$126.10 |
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
|
|
SUMATRIPTAN SUCCINATE 25 MG PO TABLET
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$128.70 |
| Rate for Payer: AlohaCare Medicaid |
$65.00
|
| Rate for Payer: AlohaCare Medicare |
$117.00
|
| Rate for Payer: Cash Price |
$84.50
|
| Rate for Payer: Devoted Health Medicare |
$128.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$117.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$110.50
|
| Rate for Payer: Humana Medicare |
$117.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$117.00
|
| Rate for Payer: MDX Hawaii PPO |
$126.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$117.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$117.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$117.00
|
| Rate for Payer: University Health Alliance Commercial |
$94.76
|
|
|
SUMATRIPTAN SUCCINATE 50 MG PO TABLET
|
Facility
|
IP
|
$122.08
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.77 |
| Max. Negotiated Rate |
$118.42 |
| Rate for Payer: Cash Price |
$79.35
|
| Rate for Payer: Health Management Network Commercial |
$103.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.87
|
| Rate for Payer: MDX Hawaii PPO |
$118.42
|
|
|
SUMATRIPTAN SUCCINATE 50 MG PO TABLET
|
Facility
|
OP
|
$122.08
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.04 |
| Max. Negotiated Rate |
$120.86 |
| Rate for Payer: AlohaCare Medicaid |
$61.04
|
| Rate for Payer: AlohaCare Medicare |
$109.87
|
| Rate for Payer: Cash Price |
$79.35
|
| Rate for Payer: Devoted Health Medicare |
$120.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$115.98
|
| Rate for Payer: Health Management Network Commercial |
$103.77
|
| Rate for Payer: Humana Medicare |
$109.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$62.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.87
|
| Rate for Payer: MDX Hawaii PPO |
$118.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.87
|
| Rate for Payer: University Health Alliance Commercial |
$88.98
|
|
|
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBCUTANEOUS SOLN
|
Facility
|
OP
|
$72.65
|
|
|
Service Code
|
HCPCS J3030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.33 |
| Max. Negotiated Rate |
$79.64 |
| Rate for Payer: AlohaCare Medicaid |
$36.33
|
| Rate for Payer: AlohaCare Medicaid |
$33.84
|
| Rate for Payer: AlohaCare Medicare |
$60.91
|
| Rate for Payer: AlohaCare Medicare |
$65.39
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$43.99
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$43.99
|
| Rate for Payer: Devoted Health Medicare |
$67.00
|
| Rate for Payer: Devoted Health Medicare |
$71.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$79.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$79.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$79.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$79.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.02
|
| Rate for Payer: Health Management Network Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$57.53
|
| Rate for Payer: Humana Medicare |
$65.39
|
| Rate for Payer: Humana Medicare |
$60.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.39
|
| Rate for Payer: MDX Hawaii PPO |
$70.47
|
| Rate for Payer: MDX Hawaii PPO |
$65.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.91
|
| Rate for Payer: University Health Alliance Commercial |
$52.95
|
| Rate for Payer: University Health Alliance Commercial |
$49.33
|
|
