|
AMIKACIN 500 MG/2 ML (250 MG/ML) INJ SOLN FOR OTHER USE
|
Facility
|
OP
|
$45.87
|
|
|
Service Code
|
NDC 23155029031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.93 |
| Max. Negotiated Rate |
$45.41 |
| Rate for Payer: AlohaCare Medicaid |
$22.93
|
| Rate for Payer: AlohaCare Medicare |
$41.28
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Devoted Health Medicare |
$45.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.58
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Humana Medicare |
$41.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.28
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.28
|
| Rate for Payer: University Health Alliance Commercial |
$33.43
|
|
|
AMIKACIN 500 MG/2 ML INJ SOLN
|
Facility
|
OP
|
$47.08
|
|
|
Service Code
|
HCPCS J0278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$46.61 |
| Rate for Payer: AlohaCare Medicaid |
$23.54
|
| Rate for Payer: AlohaCare Medicaid |
$24.14
|
| Rate for Payer: AlohaCare Medicaid |
$22.93
|
| Rate for Payer: AlohaCare Medicare |
$43.46
|
| Rate for Payer: AlohaCare Medicare |
$41.28
|
| Rate for Payer: AlohaCare Medicare |
$42.37
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$31.39
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$31.39
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$47.81
|
| Rate for Payer: Devoted Health Medicare |
$46.61
|
| Rate for Payer: Devoted Health Medicare |
$45.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.73
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$40.02
|
| Rate for Payer: Health Management Network Commercial |
$41.05
|
| Rate for Payer: Humana Medicare |
$42.37
|
| Rate for Payer: Humana Medicare |
$41.28
|
| Rate for Payer: Humana Medicare |
$43.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.46
|
| Rate for Payer: MDX Hawaii PPO |
$46.84
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: MDX Hawaii PPO |
$45.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.37
|
| Rate for Payer: University Health Alliance Commercial |
$35.20
|
| Rate for Payer: University Health Alliance Commercial |
$34.32
|
| Rate for Payer: University Health Alliance Commercial |
$33.43
|
|
|
AMIKACIN 500 MG/2 ML INJ SOLN
|
Facility
|
IP
|
$47.08
|
|
|
Service Code
|
HCPCS J0278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.02 |
| Max. Negotiated Rate |
$45.67 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$31.39
|
| Rate for Payer: Health Management Network Commercial |
$41.05
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$40.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.37
|
| Rate for Payer: MDX Hawaii PPO |
$45.67
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: MDX Hawaii PPO |
$46.84
|
|
|
AMIODARONE 200 MG PO TABLET
|
Facility
|
IP
|
$3.35
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Health Management Network Commercial |
$2.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.25
|
|
|
AMIODARONE 200 MG PO TABLET
|
Facility
|
OP
|
$3.35
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.32 |
| Rate for Payer: AlohaCare Medicaid |
$1.68
|
| Rate for Payer: AlohaCare Medicare |
$3.02
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Devoted Health Medicare |
$3.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.18
|
| Rate for Payer: Health Management Network Commercial |
$2.85
|
| Rate for Payer: Humana Medicare |
$3.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.02
|
| Rate for Payer: University Health Alliance Commercial |
$2.44
|
|
|
AMIODARONE 50 MG/ML IV SOLN
|
Facility
|
IP
|
$24.30
|
|
|
Service Code
|
HCPCS J0282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.66 |
| Max. Negotiated Rate |
$23.57 |
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Health Management Network Commercial |
$20.66
|
| Rate for Payer: Health Management Network Commercial |
$9.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.87
|
| Rate for Payer: MDX Hawaii PPO |
$10.72
|
| Rate for Payer: MDX Hawaii PPO |
$23.57
|
|
|
AMIODARONE 50 MG/ML IV SOLN
|
Facility
|
OP
|
$24.30
|
|
|
Service Code
|
HCPCS J0282
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$24.06 |
| Rate for Payer: AlohaCare Medicaid |
$12.15
|
| Rate for Payer: AlohaCare Medicaid |
$5.53
|
| Rate for Payer: AlohaCare Medicare |
$9.95
|
| Rate for Payer: AlohaCare Medicare |
$21.87
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Cash Price |
$15.80
|
| Rate for Payer: Cash Price |
$7.18
|
| Rate for Payer: Devoted Health Medicare |
$10.94
|
| Rate for Payer: Devoted Health Medicare |
$24.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.09
|
| Rate for Payer: Health Management Network Commercial |
$20.66
|
| Rate for Payer: Health Management Network Commercial |
$9.39
|
| Rate for Payer: Humana Medicare |
$21.87
|
| Rate for Payer: Humana Medicare |
$9.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.87
|
| Rate for Payer: MDX Hawaii PPO |
$23.57
|
| Rate for Payer: MDX Hawaii PPO |
$10.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.95
|
| Rate for Payer: University Health Alliance Commercial |
$17.71
|
| Rate for Payer: University Health Alliance Commercial |
$8.05
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN
|
Facility
|
OP
|
$161.66
|
|
|
Service Code
|
HCPCS J0283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$160.04 |
| Rate for Payer: AlohaCare Medicaid |
$80.83
|
| Rate for Payer: AlohaCare Medicare |
$145.49
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Devoted Health Medicare |
$160.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$145.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$153.58
|
| Rate for Payer: Health Management Network Commercial |
$137.41
|
| Rate for Payer: Humana Medicare |
$145.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$145.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$82.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$145.49
|
| Rate for Payer: MDX Hawaii PPO |
$156.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$145.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$145.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$97.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$145.49
|
| Rate for Payer: University Health Alliance Commercial |
$117.83
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN
|
Facility
|
IP
|
$161.66
|
|
|
Service Code
|
HCPCS J0283
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$137.41 |
| Max. Negotiated Rate |
$156.81 |
| Rate for Payer: Cash Price |
$105.08
|
| Rate for Payer: Health Management Network Commercial |
$137.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$145.49
|
| Rate for Payer: MDX Hawaii PPO |
$156.81
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN
|
Facility
|
OP
|
$209.27
|
|
|
Service Code
|
HCPCS J0283
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$207.18 |
| Rate for Payer: AlohaCare Medicaid |
$104.64
|
| Rate for Payer: AlohaCare Medicare |
$188.34
|
| Rate for Payer: Cash Price |
$136.03
|
| Rate for Payer: Cash Price |
$136.03
|
| Rate for Payer: Devoted Health Medicare |
$207.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$188.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$198.81
|
| Rate for Payer: Health Management Network Commercial |
$177.88
|
| Rate for Payer: Humana Medicare |
$188.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$188.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$106.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.34
|
| Rate for Payer: MDX Hawaii PPO |
$202.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$188.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$188.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$125.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$188.34
|
| Rate for Payer: University Health Alliance Commercial |
$152.54
|
|
|
AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN
|
Facility
|
IP
|
$209.27
|
|
|
Service Code
|
HCPCS J0283
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.88 |
| Max. Negotiated Rate |
$202.99 |
| Rate for Payer: Cash Price |
$136.03
|
| Rate for Payer: Health Management Network Commercial |
$177.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$188.34
|
| Rate for Payer: MDX Hawaii PPO |
$202.99
|
|
|
AMITRIPTYLINE 10 MG PO TABLET
|
Facility
|
OP
|
$1.76
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: AlohaCare Medicaid |
$0.88
|
| Rate for Payer: AlohaCare Medicare |
$1.58
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Devoted Health Medicare |
$1.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.67
|
| Rate for Payer: Health Management Network Commercial |
$1.50
|
| Rate for Payer: Humana Medicare |
$1.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.58
|
| Rate for Payer: MDX Hawaii PPO |
$1.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.58
|
| Rate for Payer: University Health Alliance Commercial |
$1.28
|
|
|
AMITRIPTYLINE 10 MG PO TABLET
|
Facility
|
IP
|
$1.76
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.58
|
| Rate for Payer: MDX Hawaii PPO |
$1.71
|
|
|
AMITRIPTYLINE 25 MG PO TABLET
|
Facility
|
OP
|
$2.85
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: AlohaCare Medicaid |
$1.43
|
| Rate for Payer: AlohaCare Medicare |
$2.56
|
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Devoted Health Medicare |
$2.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.71
|
| Rate for Payer: Health Management Network Commercial |
$2.42
|
| Rate for Payer: Humana Medicare |
$2.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.56
|
| Rate for Payer: MDX Hawaii PPO |
$2.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.56
|
| Rate for Payer: University Health Alliance Commercial |
$2.08
|
|
|
AMITRIPTYLINE 25 MG PO TABLET
|
Facility
|
IP
|
$2.85
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Cash Price |
$1.85
|
| Rate for Payer: Health Management Network Commercial |
$2.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.56
|
| Rate for Payer: MDX Hawaii PPO |
$2.76
|
|
|
AMITRIPTYLINE 50 MG PO TABLET
|
Facility
|
OP
|
$3.85
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.93 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: AlohaCare Medicaid |
$1.93
|
| Rate for Payer: AlohaCare Medicare |
$3.46
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Devoted Health Medicare |
$3.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.66
|
| Rate for Payer: Health Management Network Commercial |
$3.27
|
| Rate for Payer: Humana Medicare |
$3.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.46
|
| Rate for Payer: MDX Hawaii PPO |
$3.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.46
|
| Rate for Payer: University Health Alliance Commercial |
$2.81
|
|
|
AMITRIPTYLINE 50 MG PO TABLET
|
Facility
|
IP
|
$3.85
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.27 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Health Management Network Commercial |
$3.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.46
|
| Rate for Payer: MDX Hawaii PPO |
$3.73
|
|
|
AMLODIPINE 2.5 MG PO TABLET
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
|
|
AMLODIPINE 2.5 MG PO TABLET
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: AlohaCare Medicaid |
$0.60
|
| Rate for Payer: AlohaCare Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Devoted Health Medicare |
$1.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Humana Medicare |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.08
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
AMLODIPINE 5 MG PO TABLET
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: AlohaCare Medicaid |
$0.60
|
| Rate for Payer: AlohaCare Medicare |
$1.08
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Devoted Health Medicare |
$1.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Humana Medicare |
$1.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.08
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
AMLODIPINE 5 MG PO TABLET
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.08
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
|
|
AMMONIUM LACTATE 12 % TOP CR
|
Facility
|
IP
|
$133.92
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.83 |
| Max. Negotiated Rate |
$129.90 |
| Rate for Payer: Cash Price |
$87.05
|
| Rate for Payer: Cash Price |
$50.23
|
| Rate for Payer: Health Management Network Commercial |
$113.83
|
| Rate for Payer: Health Management Network Commercial |
$65.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$120.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.55
|
| Rate for Payer: MDX Hawaii PPO |
$74.96
|
| Rate for Payer: MDX Hawaii PPO |
$129.90
|
|
|
AMMONIUM LACTATE 12 % TOP CR
|
Facility
|
OP
|
$77.28
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.64 |
| Max. Negotiated Rate |
$76.51 |
| Rate for Payer: AlohaCare Medicaid |
$38.64
|
| Rate for Payer: AlohaCare Medicaid |
$66.96
|
| Rate for Payer: AlohaCare Medicare |
$120.53
|
| Rate for Payer: AlohaCare Medicare |
$69.55
|
| Rate for Payer: Cash Price |
$87.05
|
| Rate for Payer: Cash Price |
$50.23
|
| Rate for Payer: Devoted Health Medicare |
$76.51
|
| Rate for Payer: Devoted Health Medicare |
$132.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$120.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.42
|
| Rate for Payer: Health Management Network Commercial |
$65.69
|
| Rate for Payer: Health Management Network Commercial |
$113.83
|
| Rate for Payer: Humana Medicare |
$69.55
|
| Rate for Payer: Humana Medicare |
$120.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$120.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$120.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.55
|
| Rate for Payer: MDX Hawaii PPO |
$129.90
|
| Rate for Payer: MDX Hawaii PPO |
$74.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$120.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$120.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$120.53
|
| Rate for Payer: University Health Alliance Commercial |
$56.33
|
| Rate for Payer: University Health Alliance Commercial |
$97.61
|
|
|
AMOXICILLIN 125 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
IP
|
$7.49
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.37 |
| Max. Negotiated Rate |
$7.27 |
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Health Management Network Commercial |
$6.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.74
|
| Rate for Payer: MDX Hawaii PPO |
$7.27
|
|
|
AMOXICILLIN 125 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
OP
|
$7.49
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.75 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: AlohaCare Medicaid |
$3.75
|
| Rate for Payer: AlohaCare Medicare |
$6.74
|
| Rate for Payer: Cash Price |
$4.87
|
| Rate for Payer: Devoted Health Medicare |
$7.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.12
|
| Rate for Payer: Health Management Network Commercial |
$6.37
|
| Rate for Payer: Humana Medicare |
$6.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.74
|
| Rate for Payer: MDX Hawaii PPO |
$7.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.74
|
| Rate for Payer: University Health Alliance Commercial |
$5.46
|
|
