|
PP ciprofloxacin 500 mg tab #2 [HHSC]
|
Facility
|
IP
|
$64.89
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530913
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.16 |
| Max. Negotiated Rate |
$62.94 |
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Cash Price |
$26.41
|
| Rate for Payer: Health Management Network Commercial |
$55.16
|
| Rate for Payer: Health Management Network Commercial |
$34.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.57
|
| Rate for Payer: MDX Hawaii PPO |
$39.41
|
| Rate for Payer: MDX Hawaii PPO |
$62.94
|
|
|
PP ciprofloxacin 500 mg tab #2 [HHSC]
|
Facility
|
OP
|
$40.63
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530913
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$20.32 |
| Max. Negotiated Rate |
$39.41 |
| Rate for Payer: AlohaCare Medicaid |
$20.32
|
| Rate for Payer: AlohaCare Medicaid |
$32.45
|
| Rate for Payer: AlohaCare Medicare |
$20.32
|
| Rate for Payer: AlohaCare Medicare |
$32.45
|
| Rate for Payer: Cash Price |
$42.18
|
| Rate for Payer: Cash Price |
$26.41
|
| Rate for Payer: Devoted Health Medicare |
$22.35
|
| Rate for Payer: Devoted Health Medicare |
$35.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.60
|
| Rate for Payer: Health Management Network Commercial |
$34.54
|
| Rate for Payer: Health Management Network Commercial |
$55.16
|
| Rate for Payer: Humana Medicare |
$32.45
|
| Rate for Payer: Humana Medicare |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.32
|
| Rate for Payer: MDX Hawaii PPO |
$62.94
|
| Rate for Payer: MDX Hawaii PPO |
$39.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.45
|
| Rate for Payer: University Health Alliance Commercial |
$47.30
|
| Rate for Payer: University Health Alliance Commercial |
$29.62
|
|
|
PP clindamycin 300mg cap #4 [HHSC]
|
Facility
|
IP
|
$12.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: Health Management Network Commercial |
$10.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.01
|
| Rate for Payer: MDX Hawaii PPO |
$11.86
|
|
|
PP clindamycin 300mg cap #4 [HHSC]
|
Facility
|
OP
|
$12.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530929
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.86 |
| Rate for Payer: AlohaCare Medicaid |
$6.12
|
| Rate for Payer: AlohaCare Medicare |
$6.12
|
| Rate for Payer: Cash Price |
$7.95
|
| Rate for Payer: Devoted Health Medicare |
$6.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.62
|
| Rate for Payer: Health Management Network Commercial |
$10.40
|
| Rate for Payer: Humana Medicare |
$6.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.12
|
| Rate for Payer: University Health Alliance Commercial |
$8.91
|
|
|
PP cyclobenzapr 10 mg tab #3 [HHSC]
|
Facility
|
IP
|
$16.16
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530914
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Health Management Network Commercial |
$13.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.54
|
| Rate for Payer: MDX Hawaii PPO |
$15.68
|
|
|
PP cyclobenzapr 10 mg tab #3 [HHSC]
|
Facility
|
OP
|
$16.16
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530914
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$15.68 |
| Rate for Payer: AlohaCare Medicaid |
$8.08
|
| Rate for Payer: AlohaCare Medicare |
$8.08
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Devoted Health Medicare |
$8.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.35
|
| Rate for Payer: Health Management Network Commercial |
$13.74
|
| Rate for Payer: Humana Medicare |
$8.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.08
|
| Rate for Payer: MDX Hawaii PPO |
$15.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.08
|
| Rate for Payer: University Health Alliance Commercial |
$11.78
|
|
|
PPD Administration POC
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
4623204
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$34.00 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$12.35
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Devoted Health Medicare |
$13.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.35
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.35
|
|
|
PPD Administration POC
|
Professional
|
Both
|
$29.00
|
|
| Hospital Charge Code |
4623202
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
PPD Administration POC
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
4623202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
PPD Administration POC
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
2562303
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
PPD Administration POC
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
2562303
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$36.50
|
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Devoted Health Medicare |
$40.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$36.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.55
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$36.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.50
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.50
|
| Rate for Payer: University Health Alliance Commercial |
$17.04
|
|
|
PPD Administration POC
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 86580
|
| Hospital Charge Code |
2562303
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$12.35
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Devoted Health Medicare |
$13.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.35
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
|
|
PPD Administration POC
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
4623202
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$24.50
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Devoted Health Medicare |
$26.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$24.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.50
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.50
|
| Rate for Payer: University Health Alliance Commercial |
$27.44
|
|
|
PP dicyclomine 20 mg tab #4 [HHSC]
|
Facility
|
IP
|
$17.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: Health Management Network Commercial |
$14.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.54
|
| Rate for Payer: MDX Hawaii PPO |
$16.75
|
|
|
PP dicyclomine 20 mg tab #4 [HHSC]
|
Facility
|
OP
|
$17.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530915
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$16.75 |
| Rate for Payer: AlohaCare Medicaid |
$8.63
|
| Rate for Payer: AlohaCare Medicare |
$8.63
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: Devoted Health Medicare |
$9.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.41
|
| Rate for Payer: Health Management Network Commercial |
$14.68
|
| Rate for Payer: Humana Medicare |
$8.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.63
|
| Rate for Payer: MDX Hawaii PPO |
$16.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.63
|
| Rate for Payer: University Health Alliance Commercial |
$12.59
|
|
|
PP diphenhyd 12.5 mg/5 mL 60 mL [HHSC]
|
Facility
|
OP
|
$3.98
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530927
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: AlohaCare Medicaid |
$1.99
|
| Rate for Payer: AlohaCare Medicaid |
$6.33
|
| Rate for Payer: AlohaCare Medicaid |
$1.94
|
| Rate for Payer: AlohaCare Medicare |
$6.33
|
| Rate for Payer: AlohaCare Medicare |
$1.99
|
| Rate for Payer: AlohaCare Medicare |
$1.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Devoted Health Medicare |
$2.13
|
| Rate for Payer: Devoted Health Medicare |
$6.97
|
| Rate for Payer: Devoted Health Medicare |
$2.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.04
|
| Rate for Payer: Health Management Network Commercial |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$3.30
|
| Rate for Payer: Humana Medicare |
$6.33
|
| Rate for Payer: Humana Medicare |
$1.94
|
| Rate for Payer: Humana Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$3.86
|
| Rate for Payer: MDX Hawaii PPO |
$3.76
|
| Rate for Payer: MDX Hawaii PPO |
$12.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.33
|
| Rate for Payer: University Health Alliance Commercial |
$2.23
|
| Rate for Payer: University Health Alliance Commercial |
$7.10
|
| Rate for Payer: University Health Alliance Commercial |
$2.17
|
|
|
PP diphenhyd 12.5 mg/5 mL 60 mL [HHSC]
|
Facility
|
IP
|
$3.98
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530927
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$3.86 |
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Health Management Network Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$3.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.58
|
| Rate for Payer: MDX Hawaii PPO |
$3.76
|
| Rate for Payer: MDX Hawaii PPO |
$12.29
|
| Rate for Payer: MDX Hawaii PPO |
$3.86
|
|
|
PP diphenhydram 25 mg cap #3 [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530911
|
|
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
|
|
|
PP diphenhydram 25 mg cap #3 [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530911
|
|
Hospital Revenue Code
|
253
|
| 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 Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$1.68
|
|
|
PP doxycycline 100 mg tab #2 [HHSC]
|
Facility
|
OP
|
$64.86
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530916
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$32.43 |
| Max. Negotiated Rate |
$62.91 |
| Rate for Payer: AlohaCare Medicaid |
$32.43
|
| Rate for Payer: AlohaCare Medicare |
$32.43
|
| Rate for Payer: Cash Price |
$42.16
|
| Rate for Payer: Devoted Health Medicare |
$35.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.62
|
| Rate for Payer: Health Management Network Commercial |
$55.13
|
| Rate for Payer: Humana Medicare |
$32.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.43
|
| Rate for Payer: MDX Hawaii PPO |
$62.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.43
|
| Rate for Payer: University Health Alliance Commercial |
$47.28
|
|
|
PP doxycycline 100 mg tab #2 [HHSC]
|
Facility
|
IP
|
$64.86
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.13 |
| Max. Negotiated Rate |
$62.91 |
| Rate for Payer: Cash Price |
$42.16
|
| Rate for Payer: Health Management Network Commercial |
$55.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.37
|
| Rate for Payer: MDX Hawaii PPO |
$62.91
|
|
|
PP emtricitabine-tenofovir 200 mg-300 mg #1 [HHSC]
|
Facility
|
IP
|
$344.05
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531071
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$292.44 |
| Max. Negotiated Rate |
$333.73 |
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$265.38
|
| Rate for Payer: Health Management Network Commercial |
$347.03
|
| Rate for Payer: Health Management Network Commercial |
$11.04
|
| Rate for Payer: Health Management Network Commercial |
$292.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$367.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$396.02
|
|
|
PP emtricitabine-tenofovir 200 mg-300 mg #1 [HHSC]
|
Facility
|
OP
|
$12.99
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531071
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$204.13
|
| Rate for Payer: AlohaCare Medicaid |
$172.03
|
| Rate for Payer: AlohaCare Medicare |
$172.03
|
| Rate for Payer: AlohaCare Medicare |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$204.13
|
| Rate for Payer: Cash Price |
$265.38
|
| Rate for Payer: Cash Price |
$8.44
|
| Rate for Payer: Cash Price |
$223.63
|
| Rate for Payer: Devoted Health Medicare |
$189.23
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Devoted Health Medicare |
$224.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$204.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$387.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$326.85
|
| Rate for Payer: Health Management Network Commercial |
$11.04
|
| Rate for Payer: Health Management Network Commercial |
$292.44
|
| Rate for Payer: Health Management Network Commercial |
$347.03
|
| Rate for Payer: Humana Medicare |
$172.03
|
| Rate for Payer: Humana Medicare |
$204.13
|
| Rate for Payer: Humana Medicare |
$6.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$309.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$367.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$208.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$175.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$204.13
|
| Rate for Payer: MDX Hawaii PPO |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$333.73
|
| Rate for Payer: MDX Hawaii PPO |
$396.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$204.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$204.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$204.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.03
|
| Rate for Payer: University Health Alliance Commercial |
$250.78
|
| Rate for Payer: University Health Alliance Commercial |
$9.47
|
| Rate for Payer: University Health Alliance Commercial |
$297.59
|
|
|
PP erythromyc oph oint 3.5gm [HHSC]
|
Facility
|
IP
|
$96.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530932
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.91 |
| Max. Negotiated Rate |
$93.47 |
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Health Management Network Commercial |
$81.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: MDX Hawaii PPO |
$93.47
|
|
|
PP erythromyc oph oint 3.5gm [HHSC]
|
Facility
|
OP
|
$96.36
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530932
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$48.18 |
| Max. Negotiated Rate |
$93.47 |
| Rate for Payer: AlohaCare Medicaid |
$48.18
|
| Rate for Payer: AlohaCare Medicare |
$48.18
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Devoted Health Medicare |
$53.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.54
|
| Rate for Payer: Health Management Network Commercial |
$81.91
|
| Rate for Payer: Humana Medicare |
$48.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.18
|
| Rate for Payer: MDX Hawaii PPO |
$93.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.18
|
| Rate for Payer: University Health Alliance Commercial |
$53.96
|
|
