|
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: Kaiser Permanente Commercial |
$0.90
|
| 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 |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| 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 |
$8.00 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$12.16
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$13.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$12.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.16
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
LAMOTRIGINE 25 MG TABLET [13981]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68084031801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
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: Kaiser Permanente Commercial |
$11,189.70
|
| 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 |
$36.66 |
| Max. Negotiated Rate |
$12,060.01 |
| Rate for Payer: AlohaCare Medicaid |
$6,216.50
|
| Rate for Payer: AlohaCare Medicare |
$9,449.08
|
| Rate for Payer: Cash Price |
$7,459.80
|
| Rate for Payer: Cash Price |
$7,459.80
|
| Rate for Payer: Devoted Health Medicare |
$10,443.72
|
| 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 |
$9,449.08
|
| 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 |
$9,449.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,189.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,340.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,449.08
|
| Rate for Payer: MDX Hawaii PPO |
$12,060.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,449.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,449.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,459.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,449.08
|
| Rate for Payer: University Health Alliance Commercial |
$9,062.41
|
|
|
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: Kaiser Permanente Commercial |
$9,557.10
|
| Rate for Payer: MDX Hawaii PPO |
$10,300.43
|
|
|
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 |
$36.66 |
| Max. Negotiated Rate |
$10,300.43 |
| Rate for Payer: AlohaCare Medicaid |
$5,309.50
|
| Rate for Payer: AlohaCare Medicare |
$8,070.44
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: Cash Price |
$6,371.40
|
| Rate for Payer: Devoted Health Medicare |
$8,919.96
|
| 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 |
$8,070.44
|
| 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 |
$8,070.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,557.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,415.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,070.44
|
| Rate for Payer: MDX Hawaii PPO |
$10,300.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,070.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,070.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,371.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,070.44
|
| Rate for Payer: University Health Alliance Commercial |
$7,740.19
|
|
|
LANSOPRAZOLE 15 MG DELAYED RELEASE,DISINTEGRATING TABLET [168911]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 65862089510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Humana Medicare |
$30.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.40
|
| 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: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
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: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
LANSOPRAZOLE 15 MG DELAYED RELEASE,DISINTEGRATING TABLET [168911]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 00378698188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Humana Medicare |
$30.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.40
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 65862089678
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Humana Medicare |
$30.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.40
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 65862089610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Humana Medicare |
$30.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.40
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 00378698288
|
|
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: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 65862089610
|
|
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: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 65862089678
|
|
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: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 00378698288
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$30.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Humana Medicare |
$30.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.40
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC
|
Facility
|
IP
|
$26,996.58
|
|
|
Service Code
|
MSDRG 418
|
| Min. Negotiated Rate |
$26,996.58 |
| Max. Negotiated Rate |
$26,996.58 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26,996.58
|
|
|
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC
|
Facility
|
IP
|
$29,603.80
|
|
|
Service Code
|
MSDRG 417
|
| Min. Negotiated Rate |
$29,603.80 |
| Max. Negotiated Rate |
$29,603.80 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29,603.80
|
|
|
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC
|
Facility
|
IP
|
$17,468.37
|
|
|
Service Code
|
MSDRG 419
|
| Min. Negotiated Rate |
$17,468.37 |
| Max. Negotiated Rate |
$17,468.37 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17,468.37
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 70069042103
|
|
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
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
NDC 70069042101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$230.86 |
| Rate for Payer: AlohaCare Medicaid |
$119.00
|
| Rate for Payer: AlohaCare Medicare |
$180.88
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Devoted Health Medicare |
$199.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$180.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$226.10
|
| Rate for Payer: Health Management Network Commercial |
$202.30
|
| Rate for Payer: Humana Medicare |
$180.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$214.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$121.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$180.88
|
| Rate for Payer: MDX Hawaii PPO |
$230.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$180.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$180.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$180.88
|
| Rate for Payer: University Health Alliance Commercial |
$173.48
|
|
|
LATANOPROST 0.005 % EYE DROPS [18621]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 70069042103
|
|
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
|
|
