|
ITRACONAZOLE 10 MG/ML ORAL SOLUTION [19928]
|
Facility
|
IP
|
$551.00
|
|
|
Service Code
|
NDC 65162008774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$468.35 |
| Max. Negotiated Rate |
$534.47 |
| Rate for Payer: Cash Price |
$330.60
|
| Rate for Payer: Health Management Network Commercial |
$468.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$495.90
|
| Rate for Payer: MDX Hawaii PPO |
$534.47
|
|
|
IVABRADINE 5 MG TABLET [128540]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 55513080060
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$24.32
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$26.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Humana Medicare |
$24.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.32
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.32
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
IVABRADINE 5 MG TABLET [128540]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 55513080060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 42799080601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
IVERMECTIN 3 MG TABLET [25820]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 42799080601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
IV PUSH EA ADDL SAME DRUG
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
4509637601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$198.05 |
| Max. Negotiated Rate |
$226.01 |
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Health Management Network Commercial |
$198.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.70
|
| Rate for Payer: MDX Hawaii PPO |
$226.01
|
|
|
IV PUSH EA ADDL SAME DRUG
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
4509637601
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$116.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$116.50
|
| Rate for Payer: AlohaCare Medicare |
$177.08
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Cash Price |
$139.80
|
| Rate for Payer: Devoted Health Medicare |
$195.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$177.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$221.35
|
| Rate for Payer: Health Management Network Commercial |
$198.05
|
| Rate for Payer: Humana Medicare |
$177.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$177.08
|
| Rate for Payer: MDX Hawaii PPO |
$226.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$177.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$177.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$177.08
|
| Rate for Payer: University Health Alliance Commercial |
$169.83
|
|
|
J-TUBE FEEDING TUBE #0200-12LV
|
Facility
|
OP
|
$536.00
|
|
|
Service Code
|
HCPCS B4087
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$519.92 |
| Rate for Payer: AlohaCare Medicaid |
$268.00
|
| Rate for Payer: AlohaCare Medicare |
$407.36
|
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Devoted Health Medicare |
$450.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$407.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$509.20
|
| Rate for Payer: Health Management Network Commercial |
$455.60
|
| Rate for Payer: Humana Medicare |
$407.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$482.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$273.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$407.36
|
| Rate for Payer: MDX Hawaii PPO |
$519.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$407.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$407.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$407.36
|
| Rate for Payer: University Health Alliance Commercial |
$390.69
|
|
|
J-TUBE FEEDING TUBE #0200-12LV
|
Facility
|
IP
|
$536.00
|
|
|
Service Code
|
HCPCS B4087
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$455.60 |
| Max. Negotiated Rate |
$519.92 |
| Rate for Payer: Cash Price |
$321.60
|
| Rate for Payer: Health Management Network Commercial |
$455.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$482.40
|
| Rate for Payer: MDX Hawaii PPO |
$519.92
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 00143950901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$52.38 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 00143950910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$52.38 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION [4237]
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 00409205105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.50
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION [4236]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
NDC 42023011310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [162740]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 71266908002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE [162740]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 71266908004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00143950801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION [4238]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00143950810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
NDC 45802046564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: AlohaCare Medicaid |
$53.00
|
| Rate for Payer: AlohaCare Medicare |
$80.56
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Devoted Health Medicare |
$89.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.70
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Humana Medicare |
$80.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.56
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.56
|
| Rate for Payer: University Health Alliance Commercial |
$77.26
|
|
|
KETOCONAZOLE 2 % SHAMPOO [14132]
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
NDC 45802046564
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.10 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
OP
|
$525.00
|
|
|
Service Code
|
NDC 61314012610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: AlohaCare Medicaid |
$262.50
|
| Rate for Payer: AlohaCare Medicare |
$399.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Devoted Health Medicare |
$441.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$399.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$498.75
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Humana Medicare |
$399.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$399.00
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$399.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$399.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$399.00
|
| Rate for Payer: University Health Alliance Commercial |
$382.67
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
NDC 61314012605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
IP
|
$525.00
|
|
|
Service Code
|
NDC 61314012610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$446.25 |
| Max. Negotiated Rate |
$509.25 |
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Health Management Network Commercial |
$446.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.50
|
| Rate for Payer: MDX Hawaii PPO |
$509.25
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
NDC 60505100301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$227.80 |
| Max. Negotiated Rate |
$259.96 |
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Health Management Network Commercial |
$227.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$241.20
|
| Rate for Payer: MDX Hawaii PPO |
$259.96
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
NDC 61314012605
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.00 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: AlohaCare Medicaid |
$132.00
|
| Rate for Payer: AlohaCare Medicare |
$200.64
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Devoted Health Medicare |
$221.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$200.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$250.80
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Humana Medicare |
$200.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$200.64
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$200.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$200.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$200.64
|
| Rate for Payer: University Health Alliance Commercial |
$192.43
|
|
|
KETOROLAC 0.5 % EYE DROPS [19733]
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
NDC 60505100301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.00 |
| Max. Negotiated Rate |
$259.96 |
| Rate for Payer: AlohaCare Medicaid |
$134.00
|
| Rate for Payer: AlohaCare Medicare |
$203.68
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Devoted Health Medicare |
$225.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$203.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$254.60
|
| Rate for Payer: Health Management Network Commercial |
$227.80
|
| Rate for Payer: Humana Medicare |
$203.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$241.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$136.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$203.68
|
| Rate for Payer: MDX Hawaii PPO |
$259.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$203.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$203.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$203.68
|
| Rate for Payer: University Health Alliance Commercial |
$195.35
|
|
