|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
OCTREOTIDE ACETATE 200 MCG/ML INJECTION SOLUTION [91280]
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
OCTREOTIDE ACETATE 200 MCG/ML INJECTION SOLUTION [91280]
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.40
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION [91278]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [24435]
|
Facility
|
OP
|
$6,040.00
|
|
|
Service Code
|
HCPCS J2353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.35 |
| Max. Negotiated Rate |
$5,858.80 |
| Rate for Payer: AlohaCare Medicaid |
$188.35
|
| Rate for Payer: AlohaCare Medicare |
$188.35
|
| Rate for Payer: Cash Price |
$3,624.00
|
| Rate for Payer: Cash Price |
$3,624.00
|
| Rate for Payer: Devoted Health Medicare |
$207.19
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$212.20
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$235.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$188.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$212.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,738.00
|
| Rate for Payer: Health Management Network Commercial |
$5,134.00
|
| Rate for Payer: Humana Medicare |
$188.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,805.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,080.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.35
|
| Rate for Payer: MDX Hawaii PPO |
$5,858.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$188.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,624.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$188.35
|
| Rate for Payer: University Health Alliance Commercial |
$4,402.56
|
|
|
OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [24435]
|
Facility
|
IP
|
$6,040.00
|
|
|
Service Code
|
HCPCS J2353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,134.00 |
| Max. Negotiated Rate |
$5,858.80 |
| Rate for Payer: Cash Price |
$3,624.00
|
| Rate for Payer: Health Management Network Commercial |
$5,134.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,858.80
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [24436]
|
Facility
|
OP
|
$8,796.00
|
|
|
Service Code
|
HCPCS J2353
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.35 |
| Max. Negotiated Rate |
$8,532.12 |
| Rate for Payer: AlohaCare Medicaid |
$188.35
|
| Rate for Payer: AlohaCare Medicare |
$188.35
|
| Rate for Payer: Cash Price |
$5,277.60
|
| Rate for Payer: Cash Price |
$5,277.60
|
| Rate for Payer: Devoted Health Medicare |
$207.19
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$212.20
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$235.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$188.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$212.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,356.20
|
| Rate for Payer: Health Management Network Commercial |
$7,476.60
|
| Rate for Payer: Humana Medicare |
$188.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,541.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,485.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.35
|
| Rate for Payer: MDX Hawaii PPO |
$8,532.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$188.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,277.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$188.35
|
| Rate for Payer: University Health Alliance Commercial |
$6,411.40
|
|
|
OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE [24436]
|
Facility
|
IP
|
$8,796.00
|
|
|
Service Code
|
HCPCS J2353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,476.60 |
| Max. Negotiated Rate |
$8,532.12 |
| Rate for Payer: Cash Price |
$5,277.60
|
| Rate for Payer: Health Management Network Commercial |
$7,476.60
|
| Rate for Payer: MDX Hawaii PPO |
$8,532.12
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
NDC 70756060730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.76 |
| Max. Negotiated Rate |
$170.72 |
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$167.20
|
| Rate for Payer: Health Management Network Commercial |
$149.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.76
|
| Rate for Payer: MDX Hawaii PPO |
$170.72
|
| Rate for Payer: University Health Alliance Commercial |
$128.29
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
NDC 70756060730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$170.72 |
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Health Management Network Commercial |
$149.60
|
| Rate for Payer: MDX Hawaii PPO |
$170.72
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
NDC 64380017301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
NDC 64380017302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 55111026381
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 64380017302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.03 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: University Health Alliance Commercial |
$38.63
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 64380017301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.03 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: University Health Alliance Commercial |
$38.63
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 55111026381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS J2359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.20
|
| Rate for Payer: University Health Alliance Commercial |
$77.99
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION [38263]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS J2359
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 68084074001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 68084074011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 68084074001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
OLANZAPINE 10 MG TABLET [17937]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 68084074011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
OLANZAPINE 20 MG TABLET [28158]
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
NDC 68084052901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.02 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.02
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
| Rate for Payer: University Health Alliance Commercial |
$74.35
|
|
|
OLANZAPINE 20 MG TABLET [28158]
|
Facility
|
OP
|
$102.00
|
|
|
Service Code
|
NDC 68084052911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.02 |
| Max. Negotiated Rate |
$98.94 |
| Rate for Payer: Cash Price |
$61.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$86.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.02
|
| Rate for Payer: MDX Hawaii PPO |
$98.94
|
| Rate for Payer: University Health Alliance Commercial |
$74.35
|
|
