|
PP magic mouthwash 4 oz [HHSC]
|
Facility
|
IP
|
$467.72
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530946
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.56 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
|
|
PP meclizine 25 mg tab #3 [HHSC]
|
Facility
|
IP
|
$14.28
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.14 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Health Management Network Commercial |
$12.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.85
|
| Rate for Payer: MDX Hawaii PPO |
$13.85
|
|
|
PP meclizine 25 mg tab #3 [HHSC]
|
Facility
|
OP
|
$14.28
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530947
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.85 |
| Rate for Payer: AlohaCare Medicaid |
$7.14
|
| Rate for Payer: AlohaCare Medicare |
$7.14
|
| Rate for Payer: Cash Price |
$9.28
|
| Rate for Payer: Devoted Health Medicare |
$7.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.57
|
| Rate for Payer: Health Management Network Commercial |
$12.14
|
| Rate for Payer: Humana Medicare |
$7.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.14
|
| Rate for Payer: University Health Alliance Commercial |
$10.41
|
|
|
PP mupirocin 2% oint 22gm [HHSC]
|
Facility
|
IP
|
$65.18
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.40 |
| Max. Negotiated Rate |
$63.22 |
| Rate for Payer: Kaiser Permanente Commercial |
$177.16
|
| Rate for Payer: Cash Price |
$42.37
|
| Rate for Payer: Cash Price |
$127.95
|
| Rate for Payer: Health Management Network Commercial |
$55.40
|
| Rate for Payer: Health Management Network Commercial |
$167.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.66
|
| Rate for Payer: MDX Hawaii PPO |
$190.93
|
| Rate for Payer: MDX Hawaii PPO |
$63.22
|
|
|
PP mupirocin 2% oint 22gm [HHSC]
|
Facility
|
OP
|
$196.84
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530926
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$98.42 |
| Max. Negotiated Rate |
$190.93 |
| Rate for Payer: AlohaCare Medicaid |
$98.42
|
| Rate for Payer: AlohaCare Medicaid |
$32.59
|
| Rate for Payer: AlohaCare Medicare |
$98.42
|
| Rate for Payer: AlohaCare Medicare |
$32.59
|
| Rate for Payer: Cash Price |
$42.37
|
| Rate for Payer: Cash Price |
$127.95
|
| Rate for Payer: Devoted Health Medicare |
$108.26
|
| Rate for Payer: Devoted Health Medicare |
$35.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$187.00
|
| Rate for Payer: Health Management Network Commercial |
$167.31
|
| Rate for Payer: Health Management Network Commercial |
$55.40
|
| Rate for Payer: Humana Medicare |
$32.59
|
| Rate for Payer: Humana Medicare |
$98.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$177.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$100.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.42
|
| Rate for Payer: MDX Hawaii PPO |
$63.22
|
| Rate for Payer: MDX Hawaii PPO |
$190.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.59
|
| Rate for Payer: University Health Alliance Commercial |
$36.50
|
| Rate for Payer: University Health Alliance Commercial |
$110.23
|
|
|
PP naloxone 4 mg/0.1 mL nasal spray #2 [HHSC]
|
Facility
|
IP
|
$288.32
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2531160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$245.07 |
| Max. Negotiated Rate |
$279.67 |
| Rate for Payer: Cash Price |
$187.41
|
| Rate for Payer: Health Management Network Commercial |
$245.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.49
|
| Rate for Payer: MDX Hawaii PPO |
$279.67
|
|
|
PP naloxone 4 mg/0.1 mL nasal spray #2 [HHSC]
|
Facility
|
OP
|
$288.32
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2531160
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$144.16 |
| Max. Negotiated Rate |
$279.67 |
| Rate for Payer: AlohaCare Medicaid |
$144.16
|
| Rate for Payer: AlohaCare Medicare |
$144.16
|
| Rate for Payer: Cash Price |
$187.41
|
| Rate for Payer: Devoted Health Medicare |
$158.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$144.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$273.90
|
| Rate for Payer: Health Management Network Commercial |
$245.07
|
| Rate for Payer: Humana Medicare |
$144.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$147.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$144.16
|
| Rate for Payer: MDX Hawaii PPO |
$279.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$144.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$144.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$144.16
|
| Rate for Payer: University Health Alliance Commercial |
$161.46
|
|
|
PP neomy/poly/HC otic 10 mL [HHSC]
|
Facility
|
OP
|
$461.20
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530948
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$230.60 |
| Max. Negotiated Rate |
$447.36 |
| Rate for Payer: AlohaCare Medicaid |
$230.60
|
| Rate for Payer: AlohaCare Medicaid |
$225.40
|
| Rate for Payer: AlohaCare Medicare |
$225.40
|
| Rate for Payer: AlohaCare Medicare |
$230.60
|
| Rate for Payer: Cash Price |
$293.02
|
| Rate for Payer: Cash Price |
$299.78
|
| Rate for Payer: Devoted Health Medicare |
$253.66
|
| Rate for Payer: Devoted Health Medicare |
$247.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$225.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$230.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$428.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$438.14
|
| Rate for Payer: Health Management Network Commercial |
$392.02
|
| Rate for Payer: Health Management Network Commercial |
$383.18
|
| Rate for Payer: Humana Medicare |
$230.60
|
| Rate for Payer: Humana Medicare |
$225.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$415.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$235.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$225.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$230.60
|
| Rate for Payer: MDX Hawaii PPO |
$437.28
|
| Rate for Payer: MDX Hawaii PPO |
$447.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$225.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$230.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$225.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$230.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$230.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$225.40
|
| Rate for Payer: University Health Alliance Commercial |
$258.27
|
| Rate for Payer: University Health Alliance Commercial |
$252.45
|
|
|
PP neomy/poly/HC otic 10 mL [HHSC]
|
Facility
|
IP
|
$450.80
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$383.18 |
| Max. Negotiated Rate |
$437.28 |
| Rate for Payer: Cash Price |
$293.02
|
| Rate for Payer: Cash Price |
$299.78
|
| Rate for Payer: Health Management Network Commercial |
$383.18
|
| Rate for Payer: Health Management Network Commercial |
$392.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$415.08
|
| Rate for Payer: MDX Hawaii PPO |
$447.36
|
| Rate for Payer: MDX Hawaii PPO |
$437.28
|
|
|
PP nitroglycerin 0.4mg SL tab #25 [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530994
|
|
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 |
$2.19
|
|
|
PP nitroglycerin 0.4mg SL tab #25 [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530994
|
|
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 ondansetron ODT 4 mg tab #2 [HHSC]
|
Facility
|
IP
|
$204.52
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530949
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$173.84 |
| Max. Negotiated Rate |
$198.38 |
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cash Price |
$132.89
|
| Rate for Payer: Health Management Network Commercial |
$173.84
|
| Rate for Payer: Health Management Network Commercial |
$173.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.00
|
| Rate for Payer: MDX Hawaii PPO |
$198.31
|
| Rate for Payer: MDX Hawaii PPO |
$198.38
|
|
|
PP ondansetron ODT 4 mg tab #2 [HHSC]
|
Facility
|
OP
|
$204.44
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530949
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$102.22 |
| Max. Negotiated Rate |
$198.31 |
| Rate for Payer: AlohaCare Medicaid |
$102.22
|
| Rate for Payer: AlohaCare Medicaid |
$102.26
|
| Rate for Payer: AlohaCare Medicare |
$102.22
|
| Rate for Payer: AlohaCare Medicare |
$102.26
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cash Price |
$132.89
|
| Rate for Payer: Devoted Health Medicare |
$112.44
|
| Rate for Payer: Devoted Health Medicare |
$112.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$102.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$194.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$194.22
|
| Rate for Payer: Health Management Network Commercial |
$173.77
|
| Rate for Payer: Health Management Network Commercial |
$173.84
|
| Rate for Payer: Humana Medicare |
$102.26
|
| Rate for Payer: Humana Medicare |
$102.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.22
|
| Rate for Payer: MDX Hawaii PPO |
$198.38
|
| Rate for Payer: MDX Hawaii PPO |
$198.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.26
|
| Rate for Payer: University Health Alliance Commercial |
$149.07
|
| Rate for Payer: University Health Alliance Commercial |
$149.02
|
|
|
PP oseltamivir 6 mg/mL 60 mL [HHSC]
|
Facility
|
OP
|
$584.82
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530950
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$292.41 |
| Max. Negotiated Rate |
$567.28 |
| Rate for Payer: AlohaCare Medicaid |
$292.41
|
| Rate for Payer: AlohaCare Medicare |
$292.41
|
| Rate for Payer: Cash Price |
$380.13
|
| Rate for Payer: Devoted Health Medicare |
$321.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$292.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$555.58
|
| Rate for Payer: Health Management Network Commercial |
$497.10
|
| Rate for Payer: Humana Medicare |
$292.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$526.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$298.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$292.41
|
| Rate for Payer: MDX Hawaii PPO |
$567.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$292.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$292.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$292.41
|
| Rate for Payer: University Health Alliance Commercial |
$426.28
|
|
|
PP oseltamivir 6 mg/mL 60 mL [HHSC]
|
Facility
|
IP
|
$584.82
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$497.10 |
| Max. Negotiated Rate |
$567.28 |
| Rate for Payer: Cash Price |
$380.13
|
| Rate for Payer: Health Management Network Commercial |
$497.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$526.34
|
| Rate for Payer: MDX Hawaii PPO |
$567.28
|
|
|
PP oxycodone/APAP 5/325 mg #3 [HHSC]
|
Facility
|
IP
|
$22.83
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530951
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.41 |
| Max. Negotiated Rate |
$22.15 |
| Rate for Payer: Cash Price |
$14.84
|
| Rate for Payer: Health Management Network Commercial |
$19.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.55
|
| Rate for Payer: MDX Hawaii PPO |
$22.15
|
|
|
PP oxycodone/APAP 5/325 mg #3 [HHSC]
|
Facility
|
OP
|
$22.83
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530951
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$22.15 |
| Rate for Payer: AlohaCare Medicaid |
$11.41
|
| Rate for Payer: AlohaCare Medicare |
$11.41
|
| Rate for Payer: Cash Price |
$14.84
|
| Rate for Payer: Devoted Health Medicare |
$12.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.69
|
| Rate for Payer: Health Management Network Commercial |
$19.41
|
| Rate for Payer: Humana Medicare |
$11.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.41
|
| Rate for Payer: MDX Hawaii PPO |
$22.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.41
|
| Rate for Payer: University Health Alliance Commercial |
$16.64
|
|
|
PP oxymetazoline 0.05% nasal 15mL [HHSC]
|
Facility
|
OP
|
$33.08
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530996
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$16.54 |
| Max. Negotiated Rate |
$32.09 |
| Rate for Payer: AlohaCare Medicaid |
$16.54
|
| Rate for Payer: AlohaCare Medicaid |
$13.98
|
| Rate for Payer: AlohaCare Medicare |
$13.98
|
| Rate for Payer: AlohaCare Medicare |
$16.54
|
| Rate for Payer: Cash Price |
$18.17
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Devoted Health Medicare |
$18.19
|
| Rate for Payer: Devoted Health Medicare |
$15.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.43
|
| Rate for Payer: Health Management Network Commercial |
$28.12
|
| Rate for Payer: Health Management Network Commercial |
$23.77
|
| Rate for Payer: Humana Medicare |
$16.54
|
| Rate for Payer: Humana Medicare |
$13.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.54
|
| Rate for Payer: MDX Hawaii PPO |
$27.12
|
| Rate for Payer: MDX Hawaii PPO |
$32.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.98
|
| Rate for Payer: University Health Alliance Commercial |
$18.52
|
| Rate for Payer: University Health Alliance Commercial |
$15.66
|
|
|
PP oxymetazoline 0.05% nasal 15mL [HHSC]
|
Facility
|
IP
|
$27.96
|
|
|
Service Code
|
HCPCS A9150
|
| Hospital Charge Code |
2530996
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.77 |
| Max. Negotiated Rate |
$27.12 |
| Rate for Payer: Cash Price |
$18.17
|
| Rate for Payer: Cash Price |
$21.50
|
| Rate for Payer: Health Management Network Commercial |
$23.77
|
| Rate for Payer: Health Management Network Commercial |
$28.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.77
|
| Rate for Payer: MDX Hawaii PPO |
$32.09
|
| Rate for Payer: MDX Hawaii PPO |
$27.12
|
|
|
PP penicillin VK 500 mg tab #4 [HHSC]
|
Facility
|
IP
|
$25.94
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530954
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.05 |
| Max. Negotiated Rate |
$25.16 |
| Rate for Payer: Cash Price |
$16.86
|
| Rate for Payer: Health Management Network Commercial |
$22.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.35
|
| Rate for Payer: MDX Hawaii PPO |
$25.16
|
|
|
PP penicillin VK 500 mg tab #4 [HHSC]
|
Facility
|
OP
|
$25.94
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530954
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.97 |
| Max. Negotiated Rate |
$25.16 |
| Rate for Payer: AlohaCare Medicaid |
$12.97
|
| Rate for Payer: AlohaCare Medicare |
$12.97
|
| Rate for Payer: Cash Price |
$16.86
|
| Rate for Payer: Devoted Health Medicare |
$14.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.64
|
| Rate for Payer: Health Management Network Commercial |
$22.05
|
| Rate for Payer: Humana Medicare |
$12.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.97
|
| Rate for Payer: MDX Hawaii PPO |
$25.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.97
|
| Rate for Payer: University Health Alliance Commercial |
$18.91
|
|
|
PP phenazopyrid 200mg tab #3 [HHSC]
|
Facility
|
IP
|
$68.31
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530955
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.06 |
| Max. Negotiated Rate |
$66.26 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$58.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.48
|
| Rate for Payer: MDX Hawaii PPO |
$66.26
|
|
|
PP phenazopyrid 200mg tab #3 [HHSC]
|
Facility
|
OP
|
$68.31
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530955
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$34.16 |
| Max. Negotiated Rate |
$66.26 |
| Rate for Payer: AlohaCare Medicaid |
$34.16
|
| Rate for Payer: AlohaCare Medicare |
$34.16
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Devoted Health Medicare |
$37.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.89
|
| Rate for Payer: Health Management Network Commercial |
$58.06
|
| Rate for Payer: Humana Medicare |
$34.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.16
|
| Rate for Payer: MDX Hawaii PPO |
$66.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.16
|
| Rate for Payer: University Health Alliance Commercial |
$49.79
|
|
|
PP prednisone 20 mg tab #3 [HHSC]
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530957
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.04 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cash Price |
$2.68
|
| Rate for Payer: Health Management Network Commercial |
$4.04
|
| Rate for Payer: Health Management Network Commercial |
$3.50
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.28
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
| Rate for Payer: MDX Hawaii PPO |
$4.00
|
| Rate for Payer: MDX Hawaii PPO |
$4.61
|
|
|
PP prednisone 20 mg tab #3 [HHSC]
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530957
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: AlohaCare Medicaid |
$2.38
|
| Rate for Payer: AlohaCare Medicaid |
$2.06
|
| Rate for Payer: AlohaCare Medicaid |
$2.16
|
| Rate for Payer: AlohaCare Medicare |
$2.06
|
| Rate for Payer: AlohaCare Medicare |
$2.38
|
| Rate for Payer: AlohaCare Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cash Price |
$2.68
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Devoted Health Medicare |
$2.27
|
| Rate for Payer: Devoted Health Medicare |
$2.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.91
|
| Rate for Payer: Health Management Network Commercial |
$3.50
|
| Rate for Payer: Health Management Network Commercial |
$4.04
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Humana Medicare |
$2.06
|
| Rate for Payer: Humana Medicare |
$2.16
|
| Rate for Payer: Humana Medicare |
$2.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$4.61
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
| Rate for Payer: MDX Hawaii PPO |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.06
|
| Rate for Payer: University Health Alliance Commercial |
$3.46
|
| Rate for Payer: University Health Alliance Commercial |
$3.00
|
| Rate for Payer: University Health Alliance Commercial |
$3.15
|
|
