|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 45802024414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
NDC 62332058515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.00 |
| Max. Negotiated Rate |
$141.62 |
| Rate for Payer: AlohaCare Medicaid |
$73.00
|
| Rate for Payer: AlohaCare Medicare |
$110.96
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Devoted Health Medicare |
$122.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$138.70
|
| Rate for Payer: Health Management Network Commercial |
$124.10
|
| Rate for Payer: Humana Medicare |
$110.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.96
|
| Rate for Payer: MDX Hawaii PPO |
$141.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.96
|
| Rate for Payer: University Health Alliance Commercial |
$106.42
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 45802024414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Humana Medicare |
$50.16
|
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicare |
$50.16
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Devoted Health Medicare |
$55.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.16
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.16
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [124767]
|
Facility
|
OP
|
$16,201.00
|
|
|
Service Code
|
HCPCS J9301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.46 |
| Max. Negotiated Rate |
$15,714.97 |
| Rate for Payer: AlohaCare Medicaid |
$8,100.50
|
| Rate for Payer: AlohaCare Medicaid |
$810.50
|
| Rate for Payer: AlohaCare Medicaid |
$7,290.50
|
| Rate for Payer: AlohaCare Medicare |
$1,231.96
|
| Rate for Payer: AlohaCare Medicare |
$12,312.76
|
| Rate for Payer: AlohaCare Medicare |
$11,081.56
|
| Rate for Payer: Cash Price |
$8,748.60
|
| Rate for Payer: Cash Price |
$9,720.60
|
| Rate for Payer: Cash Price |
$9,720.60
|
| Rate for Payer: Cash Price |
$8,748.60
|
| Rate for Payer: Cash Price |
$972.60
|
| Rate for Payer: Cash Price |
$972.60
|
| Rate for Payer: Devoted Health Medicare |
$1,361.64
|
| Rate for Payer: Devoted Health Medicare |
$12,248.04
|
| Rate for Payer: Devoted Health Medicare |
$13,608.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,231.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,081.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12,312.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$78.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13,851.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,539.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,390.95
|
| Rate for Payer: Health Management Network Commercial |
$12,393.85
|
| Rate for Payer: Health Management Network Commercial |
$1,377.85
|
| Rate for Payer: Health Management Network Commercial |
$13,770.85
|
| Rate for Payer: Humana Medicare |
$1,231.96
|
| Rate for Payer: Humana Medicare |
$12,312.76
|
| Rate for Payer: Humana Medicare |
$11,081.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,458.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,580.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,122.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,262.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,436.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$826.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,081.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$12,312.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,231.96
|
| Rate for Payer: MDX Hawaii PPO |
$1,572.37
|
| Rate for Payer: MDX Hawaii PPO |
$14,143.57
|
| Rate for Payer: MDX Hawaii PPO |
$15,714.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,081.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12,312.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,231.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,231.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$12,312.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,081.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,748.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,720.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$972.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$12,312.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,081.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,231.96
|
| Rate for Payer: University Health Alliance Commercial |
$11,808.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,181.55
|
| Rate for Payer: University Health Alliance Commercial |
$10,628.09
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [124767]
|
Facility
|
IP
|
$1,621.00
|
|
|
Service Code
|
HCPCS J9301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,377.85 |
| Max. Negotiated Rate |
$1,572.37 |
| Rate for Payer: Cash Price |
$972.60
|
| Rate for Payer: Cash Price |
$8,748.60
|
| Rate for Payer: Cash Price |
$9,720.60
|
| Rate for Payer: Health Management Network Commercial |
$1,377.85
|
| Rate for Payer: Health Management Network Commercial |
$13,770.85
|
| Rate for Payer: Health Management Network Commercial |
$12,393.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,122.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,580.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,458.90
|
| Rate for Payer: MDX Hawaii PPO |
$15,714.97
|
| Rate for Payer: MDX Hawaii PPO |
$14,143.57
|
| Rate for Payer: MDX Hawaii PPO |
$1,572.37
|
|
|
OBT BLADELESS-LONG 8MM 470360
|
Facility
|
IP
|
$158.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.30 |
| Max. Negotiated Rate |
$153.26 |
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
|
|
OBT BLADELESS-LONG 8MM 470360
|
Facility
|
OP
|
$158.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$79.00 |
| Max. Negotiated Rate |
$153.26 |
| Rate for Payer: AlohaCare Medicaid |
$79.00
|
| Rate for Payer: AlohaCare Medicare |
$120.08
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Devoted Health Medicare |
$132.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$120.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$150.10
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Humana Medicare |
$120.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$120.08
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$120.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$120.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$120.08
|
| Rate for Payer: University Health Alliance Commercial |
$115.17
|
|
|
OBTURATOR BLADELESS 8MM 470359
|
Facility
|
IP
|
$150.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
|
|
OBTURATOR BLADELESS 8MM 470359
|
Facility
|
OP
|
$150.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicare |
$114.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Devoted Health Medicare |
$126.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$114.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.00
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
|
|
OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION [91279]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J2354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
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: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| 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: Humana Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| 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: Kaiser Permanente Commercial |
$161.10
|
| 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: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$136.04
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Devoted Health Medicare |
$150.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$136.04
|
| 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: Humana Medicare |
$136.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$136.04
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$136.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$136.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$136.04
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
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: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
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: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$14.44
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| 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: Humana Medicare |
$14.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.44
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
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: Kaiser Permanente Commercial |
$5,436.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,858.80
|
|
|
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 |
$212.20 |
| Max. Negotiated Rate |
$5,858.80 |
| Rate for Payer: AlohaCare Medicaid |
$3,020.00
|
| Rate for Payer: AlohaCare Medicare |
$4,590.40
|
| Rate for Payer: Cash Price |
$3,624.00
|
| Rate for Payer: Cash Price |
$3,624.00
|
| Rate for Payer: Devoted Health Medicare |
$5,073.60
|
| 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 |
$4,590.40
|
| 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 |
$4,590.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,436.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,080.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,590.40
|
| Rate for Payer: MDX Hawaii PPO |
$5,858.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,590.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,590.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,624.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,590.40
|
| Rate for Payer: University Health Alliance Commercial |
$4,402.56
|
|
|
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: Kaiser Permanente Commercial |
$7,916.40
|
| Rate for Payer: MDX Hawaii PPO |
$8,532.12
|
|
|
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 |
$212.20 |
| Max. Negotiated Rate |
$8,532.12 |
| Rate for Payer: AlohaCare Medicaid |
$4,398.00
|
| Rate for Payer: AlohaCare Medicare |
$6,684.96
|
| Rate for Payer: Cash Price |
$5,277.60
|
| Rate for Payer: Cash Price |
$5,277.60
|
| Rate for Payer: Devoted Health Medicare |
$7,388.64
|
| 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 |
$6,684.96
|
| 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 |
$6,684.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,916.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,485.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,684.96
|
| Rate for Payer: MDX Hawaii PPO |
$8,532.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,684.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,684.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,277.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,684.96
|
| Rate for Payer: University Health Alliance Commercial |
$6,411.40
|
|
|
OFLOXACIN 0.3 % EYE DROPS [19746]
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
NDC 70756060730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.00 |
| Max. Negotiated Rate |
$170.72 |
| Rate for Payer: AlohaCare Medicaid |
$88.00
|
| Rate for Payer: AlohaCare Medicare |
$133.76
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Devoted Health Medicare |
$147.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$133.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$167.20
|
| Rate for Payer: Health Management Network Commercial |
$149.60
|
| Rate for Payer: Humana Medicare |
$133.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$158.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$133.76
|
| Rate for Payer: MDX Hawaii PPO |
$170.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$133.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$133.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$133.76
|
| 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: Kaiser Permanente Commercial |
$158.40
|
| Rate for Payer: MDX Hawaii PPO |
$170.72
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 55111026381
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$8.36
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$9.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$8.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.36
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.36
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 64380017301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: AlohaCare Medicaid |
$26.50
|
| Rate for Payer: AlohaCare Medicare |
$40.28
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Devoted Health Medicare |
$44.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Humana Medicare |
$40.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.28
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.28
|
| Rate for Payer: University Health Alliance Commercial |
$38.63
|
|
|
OLANZAPINE 10 MG DISINTEGRATING TABLET [28160]
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
NDC 64380017302
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: AlohaCare Medicaid |
$26.50
|
| Rate for Payer: AlohaCare Medicare |
$40.28
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Devoted Health Medicare |
$44.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Humana Medicare |
$40.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.28
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.28
|
| 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: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
