|
METHIMAZOLE 5 MG TABLET [10553]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687066911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
METHIMAZOLE 5 MG TABLET [10553]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687035701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
METHIMAZOLE 5 MG TABLET [10553]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687066911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION [127749]
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS J2800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$28.88
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Devoted Health Medicare |
$31.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.10
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Humana Medicare |
$28.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.88
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
METHOCARBAMOL 100 MG/ML INJECTION SOLUTION [127749]
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS J2800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [82181]
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
HCPCS J9260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: AlohaCare Medicare |
$107.92
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Devoted Health Medicare |
$119.28
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$107.92
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$85.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$103.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
METHOTREXATE SODIUM 25 MG/ML INJECTION SOLUTION [82181]
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
HCPCS J9260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
|
METHOTREXATE SODIUM 2.5 MG TABLET [13594]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J8610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
METHOTREXATE SODIUM 2.5 MG TABLET [13594]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J8610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Humana Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION [117030]
|
Facility
|
OP
|
$155.00
|
|
|
Service Code
|
HCPCS J9260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: AlohaCare Medicaid |
$77.50
|
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: AlohaCare Medicare |
$117.80
|
| Rate for Payer: AlohaCare Medicare |
$28.88
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Devoted Health Medicare |
$130.20
|
| Rate for Payer: Devoted Health Medicare |
$31.92
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$117.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$147.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.10
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$117.80
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Humana Medicare |
$28.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$117.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.88
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$117.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$117.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$117.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.88
|
| Rate for Payer: University Health Alliance Commercial |
$112.98
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION [117030]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS J9260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION [134059]
|
Facility
|
IP
|
$704.00
|
|
|
Service Code
|
HCPCS Q9968
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$598.40 |
| Max. Negotiated Rate |
$682.88 |
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Health Management Network Commercial |
$598.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$633.60
|
| Rate for Payer: MDX Hawaii PPO |
$682.88
|
|
|
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS J2210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.90 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
|
|
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION [10571]
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS J2210
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.06 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: AlohaCare Medicaid |
$47.00
|
| Rate for Payer: AlohaCare Medicare |
$71.44
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Devoted Health Medicare |
$78.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$22.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$22.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$89.30
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Humana Medicare |
$71.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.44
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.44
|
| Rate for Payer: University Health Alliance Commercial |
$68.52
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
NDC 00054063905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.75 |
| Max. Negotiated Rate |
$130.95 |
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
NDC 00054063905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$130.95 |
| Rate for Payer: AlohaCare Medicaid |
$67.50
|
| Rate for Payer: AlohaCare Medicare |
$102.60
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Devoted Health Medicare |
$113.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$128.25
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Humana Medicare |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.60
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.60
|
| Rate for Payer: University Health Alliance Commercial |
$98.40
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
NDC 70010078628
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.75 |
| Max. Negotiated Rate |
$130.95 |
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
IP
|
$142.00
|
|
|
Service Code
|
NDC 70010078612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.70 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$142.00
|
|
|
Service Code
|
NDC 70010078612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.00 |
| Max. Negotiated Rate |
$137.74 |
| Rate for Payer: AlohaCare Medicaid |
$71.00
|
| Rate for Payer: AlohaCare Medicare |
$107.92
|
| Rate for Payer: Cash Price |
$85.20
|
| Rate for Payer: Devoted Health Medicare |
$119.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.90
|
| Rate for Payer: Health Management Network Commercial |
$120.70
|
| Rate for Payer: Humana Medicare |
$107.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.92
|
| Rate for Payer: MDX Hawaii PPO |
$137.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.92
|
| Rate for Payer: University Health Alliance Commercial |
$103.50
|
|
|
METHYLERGONOVINE 0.2 MG TABLET [10572]
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
NDC 70010078628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.50 |
| Max. Negotiated Rate |
$130.95 |
| Rate for Payer: AlohaCare Medicaid |
$67.50
|
| Rate for Payer: AlohaCare Medicare |
$102.60
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Devoted Health Medicare |
$113.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$102.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$128.25
|
| Rate for Payer: Health Management Network Commercial |
$114.75
|
| Rate for Payer: Humana Medicare |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.60
|
| Rate for Payer: MDX Hawaii PPO |
$130.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.60
|
| Rate for Payer: University Health Alliance Commercial |
$98.40
|
|
|
METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION [91651]
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
NDC 65649055102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$286.45 |
| Max. Negotiated Rate |
$326.89 |
| Rate for Payer: Cash Price |
$202.20
|
| Rate for Payer: Health Management Network Commercial |
$286.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.30
|
| Rate for Payer: MDX Hawaii PPO |
$326.89
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00406114601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 31722017501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 31722017501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
METHYLPHENIDATE 20 MG TABLET [4987]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00406114601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
