|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
NDC 00574403105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$194.65 |
| Max. Negotiated Rate |
$222.13 |
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Health Management Network Commercial |
$194.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$206.10
|
| Rate for Payer: MDX Hawaii PPO |
$222.13
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
NDC 24208029505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.50 |
| Max. Negotiated Rate |
$295.85 |
| Rate for Payer: AlohaCare Medicaid |
$152.50
|
| Rate for Payer: AlohaCare Medicare |
$231.80
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Devoted Health Medicare |
$256.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$231.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$289.75
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Humana Medicare |
$231.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$274.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$155.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$231.80
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$231.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$231.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$231.80
|
| Rate for Payer: University Health Alliance Commercial |
$222.31
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
NDC 00574403105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.50 |
| Max. Negotiated Rate |
$222.13 |
| Rate for Payer: AlohaCare Medicaid |
$114.50
|
| Rate for Payer: AlohaCare Medicare |
$174.04
|
| Rate for Payer: Cash Price |
$137.40
|
| Rate for Payer: Devoted Health Medicare |
$192.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.55
|
| Rate for Payer: Health Management Network Commercial |
$194.65
|
| Rate for Payer: Humana Medicare |
$174.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$206.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$116.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.04
|
| Rate for Payer: MDX Hawaii PPO |
$222.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.04
|
| Rate for Payer: University Health Alliance Commercial |
$166.92
|
|
|
TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
NDC 24208029505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$259.25 |
| Max. Negotiated Rate |
$295.85 |
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$274.50
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS [124422]
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
NDC 24208029005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Health Management Network Commercial |
$42.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.00
|
| Rate for Payer: MDX Hawaii PPO |
$48.50
|
|
|
TOBRAMYCIN 0.3 % EYE DROPS [124422]
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
NDC 24208029005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.00 |
| Max. Negotiated Rate |
$48.50 |
| Rate for Payer: AlohaCare Medicaid |
$25.00
|
| Rate for Payer: AlohaCare Medicare |
$38.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Devoted Health Medicare |
$42.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.50
|
| Rate for Payer: Health Management Network Commercial |
$42.50
|
| Rate for Payer: Humana Medicare |
$38.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.00
|
| Rate for Payer: MDX Hawaii PPO |
$48.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.00
|
| Rate for Payer: University Health Alliance Commercial |
$36.45
|
|
|
TOBRAMYCIN 0.3 % EYE OINTMENT [125508]
|
Facility
|
IP
|
$588.00
|
|
|
Service Code
|
NDC 00078081301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$570.36 |
| Rate for Payer: Cash Price |
$352.80
|
| Rate for Payer: Health Management Network Commercial |
$499.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$529.20
|
| Rate for Payer: MDX Hawaii PPO |
$570.36
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [11565]
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: AlohaCare Medicaid |
$100.00
|
| Rate for Payer: AlohaCare Medicare |
$152.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Devoted Health Medicare |
$168.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.00
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Humana Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: MDX Hawaii PPO |
$194.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$152.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$120.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: University Health Alliance Commercial |
$145.78
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [11565]
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.00
|
| Rate for Payer: MDX Hawaii PPO |
$194.00
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [39918]
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicaid |
$46.00
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicaid |
$46.50
|
| Rate for Payer: AlohaCare Medicare |
$70.68
|
| Rate for Payer: AlohaCare Medicare |
$29.64
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: AlohaCare Medicare |
$15.20
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: AlohaCare Medicare |
$69.92
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$77.28
|
| Rate for Payer: Devoted Health Medicare |
$32.76
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$26.04
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$78.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Humana Medicare |
$15.20
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Humana Medicare |
$69.92
|
| Rate for Payer: Humana Medicare |
$29.64
|
| Rate for Payer: Humana Medicare |
$70.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.20
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.64
|
| Rate for Payer: University Health Alliance Commercial |
$67.06
|
| Rate for Payer: University Health Alliance Commercial |
$67.79
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [39918]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
IP
|
$626.00
|
|
|
Service Code
|
NDC 00078087601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$532.10 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
NDC 00078087601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$313.00 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: AlohaCare Medicaid |
$313.00
|
| Rate for Payer: AlohaCare Medicare |
$475.76
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Devoted Health Medicare |
$525.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$475.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$594.70
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Humana Medicare |
$475.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$319.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$475.76
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$475.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$475.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$475.76
|
| Rate for Payer: University Health Alliance Commercial |
$456.29
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00536132926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 27241019230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 27241019230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$25.08
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$27.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$25.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.08
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.08
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$843.00
|
|
|
Service Code
|
NDC 31722086803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$716.55 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$843.00
|
|
|
Service Code
|
NDC 49884076852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$716.55 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$843.00
|
|
|
Service Code
|
NDC 31722086803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$421.50 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: AlohaCare Medicaid |
$421.50
|
| Rate for Payer: AlohaCare Medicare |
$640.68
|
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Devoted Health Medicare |
$708.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$640.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$800.85
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Humana Medicare |
$640.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$429.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$640.68
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$640.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$640.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$640.68
|
| Rate for Payer: University Health Alliance Commercial |
$614.46
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$843.00
|
|
|
Service Code
|
NDC 49884076852
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$421.50 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: AlohaCare Medicaid |
$421.50
|
| Rate for Payer: AlohaCare Medicare |
$640.68
|
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Devoted Health Medicare |
$708.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$640.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$800.85
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Humana Medicare |
$640.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$429.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$640.68
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$640.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$640.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$640.68
|
| Rate for Payer: University Health Alliance Commercial |
$614.46
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084034401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.50 |
| 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: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| 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 Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084034411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.50 |
| 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: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.44
|
| 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 Medicare |
$14.44
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084034411
|
|
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
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084034401
|
|
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
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084034211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
