|
PP famotidine 20 mg tab #2 [HHSC]
|
Facility
|
OP
|
$26.93
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531010
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$13.46 |
| Max. Negotiated Rate |
$26.12 |
| Rate for Payer: AlohaCare Medicaid |
$13.46
|
| Rate for Payer: AlohaCare Medicare |
$13.46
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Devoted Health Medicare |
$14.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.58
|
| Rate for Payer: Health Management Network Commercial |
$22.89
|
| Rate for Payer: Humana Medicare |
$13.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.46
|
| Rate for Payer: MDX Hawaii PPO |
$26.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.46
|
| Rate for Payer: University Health Alliance Commercial |
$19.63
|
|
|
PP famotidine 20 mg tab #2 [HHSC]
|
Facility
|
IP
|
$26.93
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2531010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.89 |
| Max. Negotiated Rate |
$26.12 |
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Health Management Network Commercial |
$22.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.24
|
| Rate for Payer: MDX Hawaii PPO |
$26.12
|
|
|
PP gentamicin 0.3% oph drops 5mL [HHSC]
|
Facility
|
IP
|
$98.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.57 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
|
|
PP gentamicin 0.3% oph drops 5mL [HHSC]
|
Facility
|
OP
|
$98.32
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530933
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$49.16 |
| Max. Negotiated Rate |
$95.37 |
| Rate for Payer: AlohaCare Medicaid |
$49.16
|
| Rate for Payer: AlohaCare Medicare |
$49.16
|
| Rate for Payer: Cash Price |
$63.91
|
| Rate for Payer: Devoted Health Medicare |
$54.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.40
|
| Rate for Payer: Health Management Network Commercial |
$83.57
|
| Rate for Payer: Humana Medicare |
$49.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.16
|
| Rate for Payer: MDX Hawaii PPO |
$95.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.16
|
| Rate for Payer: University Health Alliance Commercial |
$55.06
|
|
|
PP guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
OP
|
$6.91
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530934
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: AlohaCare Medicaid |
$3.46
|
| Rate for Payer: AlohaCare Medicare |
$3.46
|
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Devoted Health Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.56
|
| Rate for Payer: Health Management Network Commercial |
$5.87
|
| Rate for Payer: Humana Medicare |
$3.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.46
|
| Rate for Payer: MDX Hawaii PPO |
$6.70
|
| 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 |
$3.87
|
|
|
PP guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
IP
|
$6.91
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.87 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Health Management Network Commercial |
$5.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.22
|
| Rate for Payer: MDX Hawaii PPO |
$6.70
|
|
|
PP guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904005300R
|
| Hospital Charge Code |
2530934
|
|
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 guaifen-dextro 100-10mg/5mL 118mL [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904005300R
|
| Hospital Charge Code |
2530934
|
|
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 hydrocod/APAP 5/325 mg #3 [HHSC]
|
Facility
|
OP
|
$13.27
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530935
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.87 |
| Rate for Payer: AlohaCare Medicaid |
$6.63
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$6.63
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Devoted Health Medicare |
$7.30
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.61
|
| Rate for Payer: Health Management Network Commercial |
$11.28
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$6.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$12.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$9.67
|
|
|
PP hydrocod/APAP 5/325 mg #3 [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$11.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.94
|
| Rate for Payer: MDX Hawaii PPO |
$12.87
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PP hydrocod/APAP 5/325 mg #6 [HHSC]
|
Facility
|
IP
|
$26.53
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.55 |
| Max. Negotiated Rate |
$25.73 |
| Rate for Payer: Cash Price |
$17.24
|
| Rate for Payer: Health Management Network Commercial |
$22.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.88
|
| Rate for Payer: MDX Hawaii PPO |
$25.73
|
|
|
PP hydrocod/APAP 5/325 mg #6 [HHSC]
|
Facility
|
OP
|
$26.53
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530936
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$25.73 |
| Rate for Payer: AlohaCare Medicaid |
$13.27
|
| Rate for Payer: AlohaCare Medicare |
$13.27
|
| Rate for Payer: Cash Price |
$17.24
|
| Rate for Payer: Devoted Health Medicare |
$14.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$22.55
|
| Rate for Payer: Humana Medicare |
$13.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.27
|
| Rate for Payer: MDX Hawaii PPO |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.27
|
| Rate for Payer: University Health Alliance Commercial |
$19.34
|
|
|
PP ibuprofen 100 mg/5 mL 118mL [HHSC]
|
Facility
|
IP
|
$23.45
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.93 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Cash Price |
$19.48
|
| Rate for Payer: Cash Price |
$25.87
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: Health Management Network Commercial |
$23.52
|
| Rate for Payer: Health Management Network Commercial |
$33.83
|
| Rate for Payer: Health Management Network Commercial |
$25.47
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Health Management Network Commercial |
$19.19
|
| Rate for Payer: Health Management Network Commercial |
$19.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: MDX Hawaii PPO |
$26.84
|
| Rate for Payer: MDX Hawaii PPO |
$38.61
|
| Rate for Payer: MDX Hawaii PPO |
$22.75
|
| Rate for Payer: MDX Hawaii PPO |
$21.90
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.07
|
|
|
PP ibuprofen 100 mg/5 mL 118mL [HHSC]
|
Facility
|
OP
|
$53.61
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530938
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$26.80 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: AlohaCare Medicaid |
$26.80
|
| Rate for Payer: AlohaCare Medicaid |
$19.90
|
| Rate for Payer: AlohaCare Medicaid |
$14.98
|
| Rate for Payer: AlohaCare Medicaid |
$11.29
|
| Rate for Payer: AlohaCare Medicaid |
$13.84
|
| Rate for Payer: AlohaCare Medicaid |
$11.72
|
| Rate for Payer: AlohaCare Medicare |
$26.80
|
| Rate for Payer: AlohaCare Medicare |
$13.84
|
| Rate for Payer: AlohaCare Medicare |
$14.98
|
| Rate for Payer: AlohaCare Medicare |
$11.72
|
| Rate for Payer: AlohaCare Medicare |
$19.90
|
| Rate for Payer: AlohaCare Medicare |
$11.29
|
| Rate for Payer: Cash Price |
$19.48
|
| Rate for Payer: Cash Price |
$17.99
|
| Rate for Payer: Cash Price |
$25.87
|
| Rate for Payer: Cash Price |
$34.85
|
| Rate for Payer: Cash Price |
$15.24
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Devoted Health Medicare |
$29.49
|
| Rate for Payer: Devoted Health Medicare |
$21.89
|
| Rate for Payer: Devoted Health Medicare |
$16.48
|
| Rate for Payer: Devoted Health Medicare |
$12.42
|
| Rate for Payer: Devoted Health Medicare |
$15.22
|
| Rate for Payer: Devoted Health Medicare |
$12.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.93
|
| Rate for Payer: Health Management Network Commercial |
$33.83
|
| Rate for Payer: Health Management Network Commercial |
$23.52
|
| Rate for Payer: Health Management Network Commercial |
$25.47
|
| Rate for Payer: Health Management Network Commercial |
$19.19
|
| Rate for Payer: Health Management Network Commercial |
$19.93
|
| Rate for Payer: Health Management Network Commercial |
$45.57
|
| Rate for Payer: Humana Medicare |
$19.90
|
| Rate for Payer: Humana Medicare |
$11.29
|
| Rate for Payer: Humana Medicare |
$14.98
|
| Rate for Payer: Humana Medicare |
$11.72
|
| Rate for Payer: Humana Medicare |
$13.84
|
| Rate for Payer: Humana Medicare |
$26.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.90
|
| Rate for Payer: MDX Hawaii PPO |
$21.90
|
| Rate for Payer: MDX Hawaii PPO |
$29.07
|
| Rate for Payer: MDX Hawaii PPO |
$22.75
|
| Rate for Payer: MDX Hawaii PPO |
$38.61
|
| Rate for Payer: MDX Hawaii PPO |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$26.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.29
|
| Rate for Payer: University Health Alliance Commercial |
$13.13
|
| Rate for Payer: University Health Alliance Commercial |
$22.29
|
| Rate for Payer: University Health Alliance Commercial |
$30.02
|
| Rate for Payer: University Health Alliance Commercial |
$16.78
|
| Rate for Payer: University Health Alliance Commercial |
$12.64
|
| Rate for Payer: University Health Alliance Commercial |
$15.50
|
|
|
PP ibuprofen 400 mg tab #3 [HHSC]
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Health Management Network Commercial |
$3.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.91
|
| Rate for Payer: MDX Hawaii PPO |
$4.21
|
|
|
PP ibuprofen 400 mg tab #3 [HHSC]
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530939
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: AlohaCare Medicaid |
$2.17
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Devoted Health Medicare |
$2.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.12
|
| Rate for Payer: Health Management Network Commercial |
$3.69
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$4.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$3.16
|
|
|
PP ibuprofen 600 mg tab #3 [HHSC]
|
Facility
|
IP
|
$6.03
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Cash Price |
$3.92
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Health Management Network Commercial |
$5.13
|
| Rate for Payer: Health Management Network Commercial |
$7.76
|
| Rate for Payer: Health Management Network Commercial |
$4.32
|
| Rate for Payer: Health Management Network Commercial |
$7.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.74
|
| Rate for Payer: MDX Hawaii PPO |
$8.86
|
| Rate for Payer: MDX Hawaii PPO |
$4.93
|
| Rate for Payer: MDX Hawaii PPO |
$5.85
|
| Rate for Payer: MDX Hawaii PPO |
$8.34
|
|
|
PP ibuprofen 600 mg tab #3 [HHSC]
|
Facility
|
OP
|
$8.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530940
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.30 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: AlohaCare Medicaid |
$4.30
|
| Rate for Payer: AlohaCare Medicaid |
$3.02
|
| Rate for Payer: AlohaCare Medicaid |
$4.57
|
| Rate for Payer: AlohaCare Medicaid |
$2.54
|
| Rate for Payer: AlohaCare Medicare |
$4.57
|
| Rate for Payer: AlohaCare Medicare |
$4.30
|
| Rate for Payer: AlohaCare Medicare |
$2.54
|
| Rate for Payer: AlohaCare Medicare |
$3.02
|
| Rate for Payer: Cash Price |
$5.93
|
| Rate for Payer: Cash Price |
$5.59
|
| Rate for Payer: Cash Price |
$3.92
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Devoted Health Medicare |
$2.79
|
| Rate for Payer: Devoted Health Medicare |
$5.02
|
| Rate for Payer: Devoted Health Medicare |
$3.32
|
| Rate for Payer: Devoted Health Medicare |
$4.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.67
|
| Rate for Payer: Health Management Network Commercial |
$7.31
|
| Rate for Payer: Health Management Network Commercial |
$4.32
|
| Rate for Payer: Health Management Network Commercial |
$7.76
|
| Rate for Payer: Health Management Network Commercial |
$5.13
|
| Rate for Payer: Humana Medicare |
$3.02
|
| Rate for Payer: Humana Medicare |
$4.57
|
| Rate for Payer: Humana Medicare |
$4.30
|
| Rate for Payer: Humana Medicare |
$2.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.30
|
| Rate for Payer: MDX Hawaii PPO |
$8.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.85
|
| Rate for Payer: MDX Hawaii PPO |
$8.34
|
| Rate for Payer: MDX Hawaii PPO |
$4.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.57
|
| Rate for Payer: University Health Alliance Commercial |
$3.70
|
| Rate for Payer: University Health Alliance Commercial |
$6.27
|
| Rate for Payer: University Health Alliance Commercial |
$4.40
|
| Rate for Payer: University Health Alliance Commercial |
$6.65
|
|
|
PP indomethacin 25 mg cap #3 [HHSC]
|
Facility
|
IP
|
$6.70
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Cash Price |
$4.36
|
| Rate for Payer: Health Management Network Commercial |
$5.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.03
|
| Rate for Payer: MDX Hawaii PPO |
$6.50
|
|
|
PP indomethacin 25 mg cap #3 [HHSC]
|
Facility
|
OP
|
$6.70
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530942
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: AlohaCare Medicaid |
$3.35
|
| Rate for Payer: AlohaCare Medicare |
$3.35
|
| Rate for Payer: Cash Price |
$4.36
|
| Rate for Payer: Devoted Health Medicare |
$3.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.37
|
| Rate for Payer: Health Management Network Commercial |
$5.70
|
| Rate for Payer: Humana Medicare |
$3.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.35
|
| Rate for Payer: MDX Hawaii PPO |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.35
|
| Rate for Payer: University Health Alliance Commercial |
$4.88
|
|
|
PP loperamide 2 mg cap #3 [HHSC]
|
Facility
|
OP
|
$14.64
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530943
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.32 |
| Max. Negotiated Rate |
$14.20 |
| Rate for Payer: AlohaCare Medicaid |
$7.32
|
| Rate for Payer: AlohaCare Medicare |
$7.32
|
| Rate for Payer: Cash Price |
$9.52
|
| Rate for Payer: Devoted Health Medicare |
$8.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.91
|
| Rate for Payer: Health Management Network Commercial |
$12.44
|
| Rate for Payer: Humana Medicare |
$7.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.32
|
| Rate for Payer: MDX Hawaii PPO |
$14.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.32
|
| Rate for Payer: University Health Alliance Commercial |
$8.20
|
|
|
PP loperamide 2 mg cap #3 [HHSC]
|
Facility
|
IP
|
$14.64
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530943
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.44 |
| Max. Negotiated Rate |
$14.20 |
| Rate for Payer: Cash Price |
$9.52
|
| Rate for Payer: Health Management Network Commercial |
$12.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.18
|
| Rate for Payer: MDX Hawaii PPO |
$14.20
|
|
|
PP LORazepam 1 mg tab #4 [HHSC]
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530944
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$18.98 |
| Rate for Payer: AlohaCare Medicaid |
$9.79
|
| Rate for Payer: AlohaCare Medicare |
$9.79
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Devoted Health Medicare |
$10.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.59
|
| Rate for Payer: Health Management Network Commercial |
$16.63
|
| Rate for Payer: Humana Medicare |
$9.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.79
|
| Rate for Payer: MDX Hawaii PPO |
$18.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.79
|
| Rate for Payer: University Health Alliance Commercial |
$14.26
|
|
|
PP LORazepam 1 mg tab #4 [HHSC]
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$18.98 |
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Health Management Network Commercial |
$16.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.61
|
| Rate for Payer: MDX Hawaii PPO |
$18.98
|
|
|
PP magic mouthwash 4 oz [HHSC]
|
Facility
|
OP
|
$467.72
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530946
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$233.86 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: AlohaCare Medicaid |
$233.86
|
| Rate for Payer: AlohaCare Medicare |
$233.86
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Devoted Health Medicare |
$257.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$233.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$444.33
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Humana Medicare |
$233.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.86
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$233.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$233.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$233.86
|
| Rate for Payer: University Health Alliance Commercial |
$340.92
|
|
