|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
NDC 45963043864
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00121115430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
LACTULOSE 10 GRAM/15 ML ORAL SOLUTION [38245]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00121115400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
NDC 54838056670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.00 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
|
|
LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
NDC 57237027424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.80 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$171.00
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.80
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
| Rate for Payer: University Health Alliance Commercial |
$131.20
|
|
|
LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
NDC 54838056670
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.80 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$171.00
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.80
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
| Rate for Payer: University Health Alliance Commercial |
$131.20
|
|
|
LAMIVUDINE 10 MG/ML ORAL SOLUTION [15881]
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
NDC 57237027424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.00 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68084031901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68084031901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68084031911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
LAMOTRIGINE 100 MG TABLET [13982]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68084031911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 68382000610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 68382000610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68084031811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68084031811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68084031801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68084031801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE [87861]
|
Facility
|
IP
|
$12,433.00
|
|
|
Service Code
|
HCPCS J1930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,568.05 |
| Max. Negotiated Rate |
$12,060.01 |
| Rate for Payer: Cash Price |
$7,459.80
|
| Rate for Payer: Health Management Network Commercial |
$10,568.05
|
| Rate for Payer: MDX Hawaii PPO |
$12,060.01
|
|
|
LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE [87861]
|
Facility
|
OP
|
$12,433.00
|
|
|
Service Code
|
HCPCS J1930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.72 |
| Max. Negotiated Rate |
$12,060.01 |
| Rate for Payer: AlohaCare Medicaid |
$35.72
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$7,459.80
|
| Rate for Payer: Cash Price |
$7,459.80
|
| Rate for Payer: Devoted Health Medicare |
$39.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$44.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,811.35
|
| Rate for Payer: Health Management Network Commercial |
$10,568.05
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,832.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,340.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$12,060.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,459.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$9,062.41
|
|
|
LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE [87860]
|
Facility
|
OP
|
$10,619.00
|
|
|
Service Code
|
HCPCS J1930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.72 |
| Max. Negotiated Rate |
$10,300.43 |
| Rate for Payer: AlohaCare Medicaid |
$35.72
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: Devoted Health Medicare |
$39.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$44.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,088.05
|
| Rate for Payer: Health Management Network Commercial |
$9,026.15
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,689.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,415.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$10,300.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,371.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$7,740.19
|
|
|
LANREOTIDE 90 MG/0.3 ML SUBCUTANEOUS SYRINGE [87860]
|
Facility
|
IP
|
$10,619.00
|
|
|
Service Code
|
HCPCS J1930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,026.15 |
| Max. Negotiated Rate |
$10,300.43 |
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: Health Management Network Commercial |
$9,026.15
|
| Rate for Payer: MDX Hawaii PPO |
$10,300.43
|
|
|
LANSOPRAZOLE 15 MG DELAYED RELEASE,DISINTEGRATING TABLET [168911]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 00378698188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
LANSOPRAZOLE 15 MG DELAYED RELEASE,DISINTEGRATING TABLET [168911]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 65862089510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
LANSOPRAZOLE 15 MG DELAYED RELEASE,DISINTEGRATING TABLET [168911]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 65862089510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
LANSOPRAZOLE 15 MG DELAYED RELEASE,DISINTEGRATING TABLET [168911]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 00378698188
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
