|
AMOXICILLIN 250 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
OP
|
$29.59
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: AlohaCare Medicaid |
$14.79
|
| Rate for Payer: AlohaCare Medicare |
$26.63
|
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Devoted Health Medicare |
$29.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.11
|
| Rate for Payer: Health Management Network Commercial |
$25.15
|
| Rate for Payer: Humana Medicare |
$26.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.63
|
| Rate for Payer: MDX Hawaii PPO |
$28.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.63
|
| Rate for Payer: University Health Alliance Commercial |
$21.57
|
|
|
AMOXICILLIN 250 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
IP
|
$29.59
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.15 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Cash Price |
$19.23
|
| Rate for Payer: Health Management Network Commercial |
$25.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.63
|
| Rate for Payer: MDX Hawaii PPO |
$28.70
|
|
|
AMOXICILLIN 250 MG PO CAP
|
Facility
|
IP
|
$1.38
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Health Management Network Commercial |
$1.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$1.34
|
|
|
AMOXICILLIN 250 MG PO CAP
|
Facility
|
OP
|
$1.38
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$1.37 |
| Rate for Payer: AlohaCare Medicaid |
$0.69
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Devoted Health Medicare |
$1.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.31
|
| Rate for Payer: Health Management Network Commercial |
$1.17
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$1.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$1.01
|
|
|
AMOXICILLIN 500 MG PO CAP
|
Facility
|
IP
|
$2.40
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Health Management Network Commercial |
$2.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$2.33
|
|
|
AMOXICILLIN 500 MG PO CAP
|
Facility
|
OP
|
$2.40
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: AlohaCare Medicaid |
$1.20
|
| Rate for Payer: AlohaCare Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.28
|
| Rate for Payer: Health Management Network Commercial |
$2.04
|
| Rate for Payer: Humana Medicare |
$2.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$2.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.16
|
| Rate for Payer: University Health Alliance Commercial |
$1.75
|
|
|
AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
OP
|
$398.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.10 |
| Max. Negotiated Rate |
$394.22 |
| Rate for Payer: AlohaCare Medicaid |
$199.10
|
| Rate for Payer: AlohaCare Medicare |
$358.38
|
| Rate for Payer: Cash Price |
$258.83
|
| Rate for Payer: Devoted Health Medicare |
$394.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$358.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$378.29
|
| Rate for Payer: Health Management Network Commercial |
$338.47
|
| Rate for Payer: Humana Medicare |
$358.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$358.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$203.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$358.38
|
| Rate for Payer: MDX Hawaii PPO |
$386.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$358.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$358.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$358.38
|
| Rate for Payer: University Health Alliance Commercial |
$290.25
|
|
|
AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
IP
|
$398.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$338.47 |
| Max. Negotiated Rate |
$386.25 |
| Rate for Payer: Cash Price |
$258.83
|
| Rate for Payer: Health Management Network Commercial |
$338.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$358.38
|
| Rate for Payer: MDX Hawaii PPO |
$386.25
|
|
|
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
IP
|
$174.29
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.15 |
| Max. Negotiated Rate |
$169.06 |
| Rate for Payer: Cash Price |
$113.29
|
| Rate for Payer: Health Management Network Commercial |
$148.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.86
|
| Rate for Payer: MDX Hawaii PPO |
$169.06
|
|
|
AMOXICILLIN-POT CLAVULANATE 400-57 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
OP
|
$174.29
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.14 |
| Max. Negotiated Rate |
$172.55 |
| Rate for Payer: AlohaCare Medicaid |
$87.14
|
| Rate for Payer: AlohaCare Medicare |
$156.86
|
| Rate for Payer: Cash Price |
$113.29
|
| Rate for Payer: Devoted Health Medicare |
$172.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$156.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$165.58
|
| Rate for Payer: Health Management Network Commercial |
$148.15
|
| Rate for Payer: Humana Medicare |
$156.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$156.86
|
| Rate for Payer: MDX Hawaii PPO |
$169.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$156.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$156.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$156.86
|
| Rate for Payer: University Health Alliance Commercial |
$127.04
|
|
|
AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABLET
|
Facility
|
IP
|
$20.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.77 |
| Max. Negotiated Rate |
$20.27 |
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Health Management Network Commercial |
$17.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.81
|
| Rate for Payer: MDX Hawaii PPO |
$20.27
|
|
|
AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABLET
|
Facility
|
OP
|
$20.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$20.69 |
| Rate for Payer: AlohaCare Medicaid |
$10.45
|
| Rate for Payer: AlohaCare Medicare |
$18.81
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Devoted Health Medicare |
$20.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.86
|
| Rate for Payer: Health Management Network Commercial |
$17.77
|
| Rate for Payer: Humana Medicare |
$18.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.81
|
| Rate for Payer: MDX Hawaii PPO |
$20.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.81
|
| Rate for Payer: University Health Alliance Commercial |
$15.23
|
|
|
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
IP
|
$386.45
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$328.48 |
| Max. Negotiated Rate |
$374.86 |
| Rate for Payer: Cash Price |
$251.19
|
| Rate for Payer: Health Management Network Commercial |
$328.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.81
|
| Rate for Payer: MDX Hawaii PPO |
$374.86
|
|
|
AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5 ML PO SUSR (PER BOTTLE) WHR
|
Facility
|
OP
|
$386.45
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.22 |
| Max. Negotiated Rate |
$382.59 |
| Rate for Payer: AlohaCare Medicaid |
$193.22
|
| Rate for Payer: AlohaCare Medicare |
$347.81
|
| Rate for Payer: Cash Price |
$251.19
|
| Rate for Payer: Devoted Health Medicare |
$382.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$347.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$367.13
|
| Rate for Payer: Health Management Network Commercial |
$328.48
|
| Rate for Payer: Humana Medicare |
$347.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$197.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$347.81
|
| Rate for Payer: MDX Hawaii PPO |
$374.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$347.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$347.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$347.81
|
| Rate for Payer: University Health Alliance Commercial |
$281.68
|
|
|
AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABLET
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: AlohaCare Medicaid |
$8.10
|
| Rate for Payer: AlohaCare Medicare |
$14.58
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Devoted Health Medicare |
$16.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.39
|
| Rate for Payer: Health Management Network Commercial |
$13.77
|
| Rate for Payer: Humana Medicare |
$14.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.58
|
| Rate for Payer: MDX Hawaii PPO |
$15.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$11.81
|
|
|
AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABLET
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.77 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: Health Management Network Commercial |
$13.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.58
|
| Rate for Payer: MDX Hawaii PPO |
$15.71
|
|
|
AMPICILLIN SODIUM 1 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$51.36
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$50.85 |
| Rate for Payer: AlohaCare Medicaid |
$25.68
|
| Rate for Payer: AlohaCare Medicare |
$46.22
|
| Rate for Payer: Cash Price |
$33.38
|
| Rate for Payer: Cash Price |
$33.38
|
| Rate for Payer: Devoted Health Medicare |
$50.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.79
|
| Rate for Payer: Health Management Network Commercial |
$43.66
|
| Rate for Payer: Humana Medicare |
$46.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.22
|
| Rate for Payer: MDX Hawaii PPO |
$49.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.22
|
| Rate for Payer: University Health Alliance Commercial |
$37.44
|
|
|
AMPICILLIN SODIUM 1 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$51.36
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.66 |
| Max. Negotiated Rate |
$49.82 |
| Rate for Payer: Cash Price |
$33.38
|
| Rate for Payer: Health Management Network Commercial |
$43.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.22
|
| Rate for Payer: MDX Hawaii PPO |
$49.82
|
|
|
AMPICILLIN SODIUM 2 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$50.87
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.24 |
| Max. Negotiated Rate |
$49.34 |
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$56.78
|
| Rate for Payer: Cash Price |
$54.22
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$43.24
|
| Rate for Payer: Health Management Network Commercial |
$70.91
|
| Rate for Payer: Health Management Network Commercial |
$74.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.78
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: MDX Hawaii PPO |
$80.92
|
| Rate for Payer: MDX Hawaii PPO |
$84.74
|
| Rate for Payer: MDX Hawaii PPO |
$49.34
|
|
|
AMPICILLIN SODIUM 2 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$83.42
|
|
|
Service Code
|
HCPCS J0290
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$82.59 |
| Rate for Payer: AlohaCare Medicaid |
$41.71
|
| Rate for Payer: AlohaCare Medicaid |
$43.68
|
| Rate for Payer: AlohaCare Medicaid |
$25.43
|
| Rate for Payer: AlohaCare Medicaid |
$22.93
|
| Rate for Payer: AlohaCare Medicare |
$41.28
|
| Rate for Payer: AlohaCare Medicare |
$45.78
|
| Rate for Payer: AlohaCare Medicare |
$75.08
|
| Rate for Payer: AlohaCare Medicare |
$78.62
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$54.22
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$54.22
|
| Rate for Payer: Cash Price |
$56.78
|
| Rate for Payer: Cash Price |
$29.82
|
| Rate for Payer: Cash Price |
$56.78
|
| Rate for Payer: Devoted Health Medicare |
$50.36
|
| Rate for Payer: Devoted Health Medicare |
$82.59
|
| Rate for Payer: Devoted Health Medicare |
$45.41
|
| Rate for Payer: Devoted Health Medicare |
$86.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.99
|
| Rate for Payer: Health Management Network Commercial |
$74.26
|
| Rate for Payer: Health Management Network Commercial |
$43.24
|
| Rate for Payer: Health Management Network Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$70.91
|
| Rate for Payer: Humana Medicare |
$45.78
|
| Rate for Payer: Humana Medicare |
$41.28
|
| Rate for Payer: Humana Medicare |
$75.08
|
| Rate for Payer: Humana Medicare |
$78.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.28
|
| Rate for Payer: MDX Hawaii PPO |
$84.74
|
| Rate for Payer: MDX Hawaii PPO |
$80.92
|
| Rate for Payer: MDX Hawaii PPO |
$49.34
|
| Rate for Payer: MDX Hawaii PPO |
$44.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.28
|
| Rate for Payer: University Health Alliance Commercial |
$63.68
|
| Rate for Payer: University Health Alliance Commercial |
$60.80
|
| Rate for Payer: University Health Alliance Commercial |
$33.43
|
| Rate for Payer: University Health Alliance Commercial |
$37.08
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$20.87
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.74 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Cash Price |
$13.57
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Health Management Network Commercial |
$17.74
|
| Rate for Payer: Health Management Network Commercial |
$39.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.31
|
| Rate for Payer: MDX Hawaii PPO |
$45.60
|
| Rate for Payer: MDX Hawaii PPO |
$20.24
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$20.87
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$20.66 |
| Rate for Payer: AlohaCare Medicaid |
$10.44
|
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$42.31
|
| Rate for Payer: AlohaCare Medicare |
$18.78
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Cash Price |
$13.57
|
| Rate for Payer: Cash Price |
$13.57
|
| Rate for Payer: Cash Price |
$30.56
|
| Rate for Payer: Devoted Health Medicare |
$20.66
|
| Rate for Payer: Devoted Health Medicare |
$46.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.66
|
| Rate for Payer: Health Management Network Commercial |
$39.96
|
| Rate for Payer: Health Management Network Commercial |
$17.74
|
| Rate for Payer: Humana Medicare |
$18.78
|
| Rate for Payer: Humana Medicare |
$42.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.31
|
| Rate for Payer: MDX Hawaii PPO |
$20.24
|
| Rate for Payer: MDX Hawaii PPO |
$45.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.31
|
| Rate for Payer: University Health Alliance Commercial |
$15.21
|
| Rate for Payer: University Health Alliance Commercial |
$34.27
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM INJ RECON.SOLN.
|
Facility
|
OP
|
$22.08
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$21.86 |
| Rate for Payer: AlohaCare Medicaid |
$11.04
|
| Rate for Payer: AlohaCare Medicaid |
$48.62
|
| Rate for Payer: AlohaCare Medicaid |
$24.56
|
| Rate for Payer: AlohaCare Medicare |
$44.21
|
| Rate for Payer: AlohaCare Medicare |
$19.87
|
| Rate for Payer: AlohaCare Medicare |
$87.52
|
| Rate for Payer: Cash Price |
$31.93
|
| Rate for Payer: Cash Price |
$63.21
|
| Rate for Payer: Cash Price |
$31.93
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Cash Price |
$63.21
|
| Rate for Payer: Devoted Health Medicare |
$21.86
|
| Rate for Payer: Devoted Health Medicare |
$96.27
|
| Rate for Payer: Devoted Health Medicare |
$48.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$92.38
|
| Rate for Payer: Health Management Network Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: Health Management Network Commercial |
$41.75
|
| Rate for Payer: Humana Medicare |
$19.87
|
| Rate for Payer: Humana Medicare |
$44.21
|
| Rate for Payer: Humana Medicare |
$87.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.52
|
| Rate for Payer: MDX Hawaii PPO |
$94.32
|
| Rate for Payer: MDX Hawaii PPO |
$47.65
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.52
|
| Rate for Payer: University Health Alliance Commercial |
$16.09
|
| Rate for Payer: University Health Alliance Commercial |
$35.80
|
| Rate for Payer: University Health Alliance Commercial |
$70.88
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM INJ RECON.SOLN.
|
Facility
|
IP
|
$97.24
|
|
|
Service Code
|
HCPCS J0295
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.65 |
| Max. Negotiated Rate |
$94.32 |
| Rate for Payer: Cash Price |
$63.21
|
| Rate for Payer: Cash Price |
$31.93
|
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: Health Management Network Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$41.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.87
|
| Rate for Payer: MDX Hawaii PPO |
$47.65
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
| Rate for Payer: MDX Hawaii PPO |
$94.32
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC
|
Facility
|
IP
|
$80,800.12
|
|
|
Service Code
|
MSDRG 240
|
| Min. Negotiated Rate |
$80,800.12 |
| Max. Negotiated Rate |
$80,800.12 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$80,800.12
|
|
