|
Streptococcus pneumoniae Antigen, CSF FSI
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS 87899
|
| Hospital Charge Code |
8228920
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: AlohaCare Medicaid |
$69.50
|
| Rate for Payer: AlohaCare Medicare |
$69.50
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Cash Price |
$90.35
|
| Rate for Payer: Devoted Health Medicare |
$76.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.07
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Humana Medicare |
$69.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.50
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.50
|
| Rate for Payer: University Health Alliance Commercial |
$31.01
|
|
|
Streptozyme FSI
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 86063
|
| Hospital Charge Code |
8228921
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$78.57 |
| Rate for Payer: AlohaCare Medicaid |
$40.50
|
| Rate for Payer: AlohaCare Medicare |
$40.50
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Devoted Health Medicare |
$44.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.77
|
| Rate for Payer: Health Management Network Commercial |
$68.85
|
| Rate for Payer: Humana Medicare |
$40.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.50
|
| Rate for Payer: MDX Hawaii PPO |
$78.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.50
|
| Rate for Payer: University Health Alliance Commercial |
$14.93
|
|
|
Streptozyme FSI
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 86063
|
| Hospital Charge Code |
8228921
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$68.85 |
| Max. Negotiated Rate |
$78.57 |
| Rate for Payer: Cash Price |
$52.65
|
| Rate for Payer: Health Management Network Commercial |
$68.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.90
|
| Rate for Payer: MDX Hawaii PPO |
$78.57
|
|
|
Strongyloides Antibody FSI
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS 86682
|
| Hospital Charge Code |
8228922
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
|
|
Strongyloides Antibody FSI
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS 86682
|
| Hospital Charge Code |
8228922
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: AlohaCare Medicaid |
$56.00
|
| Rate for Payer: AlohaCare Medicare |
$56.00
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Cash Price |
$72.80
|
| Rate for Payer: Devoted Health Medicare |
$61.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.01
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Humana Medicare |
$56.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.00
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.00
|
| Rate for Payer: University Health Alliance Commercial |
$24.88
|
|
|
succinylcholine 200 mg/10 ml vial [HHSC]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
2500797
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$25.29 |
| Rate for Payer: AlohaCare Medicaid |
$13.04
|
| Rate for Payer: AlohaCare Medicaid |
$35.16
|
| Rate for Payer: AlohaCare Medicaid |
$59.19
|
| Rate for Payer: AlohaCare Medicaid |
$57.18
|
| Rate for Payer: AlohaCare Medicare |
$57.18
|
| Rate for Payer: AlohaCare Medicare |
$59.19
|
| Rate for Payer: AlohaCare Medicare |
$13.04
|
| Rate for Payer: AlohaCare Medicare |
$35.16
|
| Rate for Payer: Cash Price |
$74.33
|
| Rate for Payer: Cash Price |
$16.95
|
| Rate for Payer: Cash Price |
$76.94
|
| Rate for Payer: Cash Price |
$76.94
|
| Rate for Payer: Cash Price |
$16.95
|
| Rate for Payer: Cash Price |
$45.71
|
| Rate for Payer: Cash Price |
$74.33
|
| Rate for Payer: Cash Price |
$45.71
|
| Rate for Payer: Devoted Health Medicare |
$65.10
|
| Rate for Payer: Devoted Health Medicare |
$14.34
|
| Rate for Payer: Devoted Health Medicare |
$62.90
|
| Rate for Payer: Devoted Health Medicare |
$38.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.80
|
| Rate for Payer: Health Management Network Commercial |
$59.77
|
| Rate for Payer: Health Management Network Commercial |
$100.61
|
| Rate for Payer: Health Management Network Commercial |
$97.21
|
| Rate for Payer: Health Management Network Commercial |
$22.16
|
| Rate for Payer: Humana Medicare |
$59.19
|
| Rate for Payer: Humana Medicare |
$57.18
|
| Rate for Payer: Humana Medicare |
$13.04
|
| Rate for Payer: Humana Medicare |
$35.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.18
|
| Rate for Payer: MDX Hawaii PPO |
$68.21
|
| Rate for Payer: MDX Hawaii PPO |
$25.29
|
| Rate for Payer: MDX Hawaii PPO |
$114.82
|
| Rate for Payer: MDX Hawaii PPO |
$110.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.18
|
| Rate for Payer: University Health Alliance Commercial |
$51.26
|
| Rate for Payer: University Health Alliance Commercial |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$83.36
|
| Rate for Payer: University Health Alliance Commercial |
$86.28
|
|
|
succinylcholine 200 mg/10 ml vial [HHSC]
|
Facility
|
IP
|
$118.37
|
|
|
Service Code
|
HCPCS J0330
|
| Hospital Charge Code |
2500797
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.61 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Cash Price |
$76.94
|
| Rate for Payer: Cash Price |
$74.33
|
| Rate for Payer: Cash Price |
$45.71
|
| Rate for Payer: Cash Price |
$16.95
|
| Rate for Payer: Health Management Network Commercial |
$97.21
|
| Rate for Payer: Health Management Network Commercial |
$100.61
|
| Rate for Payer: Health Management Network Commercial |
$22.16
|
| Rate for Payer: Health Management Network Commercial |
$59.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.53
|
| Rate for Payer: MDX Hawaii PPO |
$110.93
|
| Rate for Payer: MDX Hawaii PPO |
$25.29
|
| Rate for Payer: MDX Hawaii PPO |
$68.21
|
| Rate for Payer: MDX Hawaii PPO |
$114.82
|
|
|
sucralfate 1 gm tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
2500799
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sucralfate 1 gm tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
2500799
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sucralfate 1 gm tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079075320
|
| Hospital Charge Code |
2500799
|
|
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
|
|
|
sucralfate 1 gm tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
2500799
|
|
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
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
IP
|
$290.60
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$247.01 |
| Max. Negotiated Rate |
$281.88 |
| Rate for Payer: Cash Price |
$188.89
|
| Rate for Payer: Health Management Network Commercial |
$247.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.54
|
| Rate for Payer: MDX Hawaii PPO |
$281.88
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
OP
|
$15.73
|
|
|
Service Code
|
NDC 54879000716
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: AlohaCare Medicaid |
$7.87
|
| Rate for Payer: AlohaCare Medicare |
$7.87
|
| Rate for Payer: Cash Price |
$10.22
|
| Rate for Payer: Devoted Health Medicare |
$8.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.94
|
| Rate for Payer: Health Management Network Commercial |
$13.37
|
| Rate for Payer: Humana Medicare |
$7.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.87
|
| Rate for Payer: MDX Hawaii PPO |
$15.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.87
|
| Rate for Payer: University Health Alliance Commercial |
$11.47
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
OP
|
$290.60
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.30 |
| Max. Negotiated Rate |
$281.88 |
| Rate for Payer: AlohaCare Medicaid |
$145.30
|
| Rate for Payer: AlohaCare Medicare |
$145.30
|
| Rate for Payer: Cash Price |
$188.89
|
| Rate for Payer: Devoted Health Medicare |
$159.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$145.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$276.07
|
| Rate for Payer: Health Management Network Commercial |
$247.01
|
| Rate for Payer: Humana Medicare |
$145.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$148.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$145.30
|
| Rate for Payer: MDX Hawaii PPO |
$281.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$145.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$145.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$174.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$145.30
|
| Rate for Payer: University Health Alliance Commercial |
$211.82
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
OP
|
$137.92
|
|
|
Service Code
|
NDC 00121085416
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.96 |
| Max. Negotiated Rate |
$133.78 |
| Rate for Payer: AlohaCare Medicaid |
$68.96
|
| Rate for Payer: AlohaCare Medicare |
$68.96
|
| Rate for Payer: Cash Price |
$89.65
|
| Rate for Payer: Devoted Health Medicare |
$75.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.02
|
| Rate for Payer: Health Management Network Commercial |
$117.23
|
| Rate for Payer: Humana Medicare |
$68.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.96
|
| Rate for Payer: MDX Hawaii PPO |
$133.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.96
|
| Rate for Payer: University Health Alliance Commercial |
$100.53
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
IP
|
$137.92
|
|
|
Service Code
|
NDC 00121085416
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.23 |
| Max. Negotiated Rate |
$133.78 |
| Rate for Payer: Cash Price |
$89.65
|
| Rate for Payer: Health Management Network Commercial |
$117.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.13
|
| Rate for Payer: MDX Hawaii PPO |
$133.78
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
OP
|
$290.60
|
|
|
Service Code
|
NDC 70954025810
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.30 |
| Max. Negotiated Rate |
$281.88 |
| Rate for Payer: AlohaCare Medicaid |
$145.30
|
| Rate for Payer: AlohaCare Medicare |
$145.30
|
| Rate for Payer: Cash Price |
$188.89
|
| Rate for Payer: Devoted Health Medicare |
$159.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$145.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$276.07
|
| Rate for Payer: Health Management Network Commercial |
$247.01
|
| Rate for Payer: Humana Medicare |
$145.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$148.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$145.30
|
| Rate for Payer: MDX Hawaii PPO |
$281.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$145.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$145.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$174.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$145.30
|
| Rate for Payer: University Health Alliance Commercial |
$211.82
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
IP
|
$290.60
|
|
|
Service Code
|
NDC 65862049647
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$247.01 |
| Max. Negotiated Rate |
$281.88 |
| Rate for Payer: Cash Price |
$188.89
|
| Rate for Payer: Health Management Network Commercial |
$247.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.54
|
| Rate for Payer: MDX Hawaii PPO |
$281.88
|
|
|
sulfameth-trimeth 200-40 mg/5 mL 120 mL bottle [HHSC]
|
Facility
|
IP
|
$15.73
|
|
|
Service Code
|
NDC 54879000716
|
| Hospital Charge Code |
2500908
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Cash Price |
$10.22
|
| Rate for Payer: Health Management Network Commercial |
$13.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.26
|
|
|
sulfameth-trimeth 800-160 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687061401
|
| Hospital Charge Code |
2500804
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sulfameth-trimeth 800-160 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687053101
|
| Hospital Charge Code |
2500804
|
|
Hospital Revenue Code
|
250
|
| 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 Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sulfameth-trimeth 800-160 mg tablet [HHSC]
|
Facility
|
IP
|
$8.01
|
|
|
Service Code
|
NDC 00603578121
|
| Hospital Charge Code |
2500804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.81 |
| Max. Negotiated Rate |
$7.77 |
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Health Management Network Commercial |
$6.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.21
|
| Rate for Payer: MDX Hawaii PPO |
$7.77
|
|
|
sulfameth-trimeth 800-160 mg tablet [HHSC]
|
Facility
|
OP
|
$6.42
|
|
|
Service Code
|
NDC 65862042001
|
| Hospital Charge Code |
2500804
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$6.23 |
| Rate for Payer: AlohaCare Medicaid |
$3.21
|
| Rate for Payer: AlohaCare Medicare |
$3.21
|
| Rate for Payer: Cash Price |
$4.17
|
| Rate for Payer: Devoted Health Medicare |
$3.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.10
|
| Rate for Payer: Health Management Network Commercial |
$5.46
|
| Rate for Payer: Humana Medicare |
$3.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.21
|
| Rate for Payer: MDX Hawaii PPO |
$6.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.21
|
| Rate for Payer: University Health Alliance Commercial |
$4.68
|
|
|
sulfameth-trimeth 800-160 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084023001
|
| Hospital Charge Code |
2500804
|
|
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
|
|
|
sulfameth-trimeth 800-160 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687053101
|
| Hospital Charge Code |
2500804
|
|
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
|
|
