|
AQUAMANTYS MALLEABLE BIPOLAR
|
Facility
|
OP
|
$1,885.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$942.50 |
| Max. Negotiated Rate |
$1,828.45 |
| Rate for Payer: AlohaCare Medicaid |
$942.50
|
| Rate for Payer: AlohaCare Medicare |
$1,432.60
|
| Rate for Payer: Cash Price |
$1,131.00
|
| Rate for Payer: Devoted Health Medicare |
$1,583.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,432.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,790.75
|
| Rate for Payer: Health Management Network Commercial |
$1,602.25
|
| Rate for Payer: Humana Medicare |
$1,432.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,696.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$961.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,432.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,828.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,432.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,432.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,432.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,373.98
|
|
|
ARCOM HUM BEARING XL 44-36
|
Facility
|
OP
|
$769.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.50 |
| Max. Negotiated Rate |
$745.93 |
| Rate for Payer: AlohaCare Medicaid |
$384.50
|
| Rate for Payer: AlohaCare Medicare |
$584.44
|
| Rate for Payer: Cash Price |
$461.40
|
| Rate for Payer: Devoted Health Medicare |
$645.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$584.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$538.30
|
| Rate for Payer: Health Management Network Commercial |
$653.65
|
| Rate for Payer: Humana Medicare |
$584.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$692.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$392.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$584.44
|
| Rate for Payer: MDX Hawaii PPO |
$745.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$584.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$584.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$584.44
|
| Rate for Payer: University Health Alliance Commercial |
$430.64
|
|
|
ARCOM HUM BEARING XL 44-36
|
Facility
|
IP
|
$769.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.64 |
| Max. Negotiated Rate |
$745.93 |
| Rate for Payer: Cash Price |
$461.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$538.30
|
| Rate for Payer: Health Management Network Commercial |
$653.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$692.10
|
| Rate for Payer: MDX Hawaii PPO |
$745.93
|
| Rate for Payer: University Health Alliance Commercial |
$430.64
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [167780]
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS J0891
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$712.95 |
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Health Management Network Commercial |
$624.75
|
| Rate for Payer: Health Management Network Commercial |
$707.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$661.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$748.80
|
| Rate for Payer: MDX Hawaii PPO |
$807.04
|
| Rate for Payer: MDX Hawaii PPO |
$712.95
|
|
|
ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [167780]
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS J0891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$712.95 |
| Rate for Payer: AlohaCare Medicaid |
$367.50
|
| Rate for Payer: AlohaCare Medicaid |
$416.00
|
| Rate for Payer: AlohaCare Medicare |
$632.32
|
| Rate for Payer: AlohaCare Medicare |
$558.60
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Devoted Health Medicare |
$617.40
|
| Rate for Payer: Devoted Health Medicare |
$698.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.82
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$632.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$558.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$698.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$790.40
|
| Rate for Payer: Health Management Network Commercial |
$707.20
|
| Rate for Payer: Health Management Network Commercial |
$624.75
|
| Rate for Payer: Humana Medicare |
$558.60
|
| Rate for Payer: Humana Medicare |
$632.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$661.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$748.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$424.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$374.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$558.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$632.32
|
| Rate for Payer: MDX Hawaii PPO |
$712.95
|
| Rate for Payer: MDX Hawaii PPO |
$807.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$632.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$558.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$558.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$632.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$499.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$441.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$558.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$632.32
|
| Rate for Payer: University Health Alliance Commercial |
$535.74
|
| Rate for Payer: University Health Alliance Commercial |
$606.44
|
|
|
ARGYLER 2PART ADPTR 8888415604
|
Facility
|
OP
|
$798.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.00 |
| Max. Negotiated Rate |
$774.06 |
| Rate for Payer: AlohaCare Medicaid |
$399.00
|
| Rate for Payer: AlohaCare Medicare |
$606.48
|
| Rate for Payer: Cash Price |
$478.80
|
| Rate for Payer: Devoted Health Medicare |
$670.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$606.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$758.10
|
| Rate for Payer: Health Management Network Commercial |
$678.30
|
| Rate for Payer: Humana Medicare |
$606.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$718.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$406.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$606.48
|
| Rate for Payer: MDX Hawaii PPO |
$774.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$606.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$606.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$606.48
|
| Rate for Payer: University Health Alliance Commercial |
$581.66
|
|
|
ARGYLER 2PART ADPTR 8888415604
|
Facility
|
IP
|
$798.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$678.30 |
| Max. Negotiated Rate |
$774.06 |
| Rate for Payer: Cash Price |
$478.80
|
| Rate for Payer: Health Management Network Commercial |
$678.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$718.20
|
| Rate for Payer: MDX Hawaii PPO |
$774.06
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 62332009930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$60.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Devoted Health Medicare |
$67.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$60.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.80
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.80
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 62332009930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 50268008915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.50 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: AlohaCare Medicaid |
$37.50
|
| Rate for Payer: AlohaCare Medicare |
$57.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Devoted Health Medicare |
$63.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.25
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Humana Medicare |
$57.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.00
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.00
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
|
|
ARIPIPRAZOLE 10 MG TABLET [34369]
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 50268008915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.75 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
|
|
ARIPIPRAZOLE 15 MG TABLET [34370]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 50268009012
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicare |
$58.52
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Devoted Health Medicare |
$64.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.15
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Humana Medicare |
$58.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.52
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.52
|
| Rate for Payer: University Health Alliance Commercial |
$56.13
|
|
|
ARIPIPRAZOLE 15 MG TABLET [34370]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 50268009012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
|
|
ARIPIPRAZOLE 15 MG TABLET [34370]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 62332010030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$60.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Devoted Health Medicare |
$67.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$60.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.80
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.80
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
|
|
ARIPIPRAZOLE 15 MG TABLET [34370]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 62332010030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
ARIPIPRAZOLE 20 MG TABLET [34371]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
NDC 31722082930
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: AlohaCare Medicaid |
$57.00
|
| Rate for Payer: AlohaCare Medicare |
$86.64
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Devoted Health Medicare |
$95.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.30
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Humana Medicare |
$86.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.64
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.64
|
| Rate for Payer: University Health Alliance Commercial |
$83.09
|
|
|
ARIPIPRAZOLE 20 MG TABLET [34371]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
NDC 31722082930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
|
|
ARIPIPRAZOLE 20 MG TABLET [34371]
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
NDC 62332010130
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
|
|
ARIPIPRAZOLE 20 MG TABLET [34371]
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
NDC 62332010130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.50 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: AlohaCare Medicaid |
$56.50
|
| Rate for Payer: AlohaCare Medicare |
$85.88
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Devoted Health Medicare |
$94.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.35
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Humana Medicare |
$85.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.88
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.88
|
| Rate for Payer: University Health Alliance Commercial |
$82.37
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 62332009730
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
ARIPIPRAZOLE 2 MG TABLET [70306]
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
NDC 62332009730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$60.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Devoted Health Medicare |
$67.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$60.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.80
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.80
|
| Rate for Payer: University Health Alliance Commercial |
$58.31
|
|
|
ARIPIPRAZOLE 30 MG TABLET [34372]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 60687021321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
ARIPIPRAZOLE 30 MG TABLET [34372]
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
NDC 62332010230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.50 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: AlohaCare Medicaid |
$56.50
|
| Rate for Payer: AlohaCare Medicare |
$85.88
|
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Devoted Health Medicare |
$94.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.35
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Humana Medicare |
$85.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.88
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.88
|
| Rate for Payer: University Health Alliance Commercial |
$82.37
|
|
|
ARIPIPRAZOLE 30 MG TABLET [34372]
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
NDC 62332010230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
|
|
ARIPIPRAZOLE 30 MG TABLET [34372]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 60687021321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$7.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$8.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$7.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.60
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.60
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
