|
KWIRE W/STOP 2MM 703818
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$333.20 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
|
|
KWIRE W/STOP 2MM 703818
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.52 |
| Max. Negotiated Rate |
$380.24 |
| Rate for Payer: AlohaCare Medicaid |
$196.00
|
| Rate for Payer: AlohaCare Medicare |
$121.52
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Devoted Health Medicare |
$133.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$121.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$372.40
|
| Rate for Payer: Health Management Network Commercial |
$333.20
|
| Rate for Payer: Humana Medicare |
$121.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$352.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$199.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$121.52
|
| Rate for Payer: MDX Hawaii PPO |
$380.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$121.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$121.52
|
| Rate for Payer: University Health Alliance Commercial |
$285.73
|
|
|
K-WIRE ZIMMER 4901-10-15
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$27.90
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$30.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.00
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.90
|
| Rate for Payer: University Health Alliance Commercial |
$50.40
|
|
|
K-WIRE ZIMMER 4901-10-15
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$50.40 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.00
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: University Health Alliance Commercial |
$50.40
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687043911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687043901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687043911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
LABETALOL 100 MG TABLET [10373]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687043901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687045011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687045001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687045011
|
|
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
|
|
|
LABETALOL 200 MG TABLET [10374]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687045001
|
|
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
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) INTRAVENOUS SYRINGE [151255]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS J1920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
LABETALOL 20 MG/4 ML (5 MG/ML) INTRAVENOUS SYRINGE [151255]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS J1920
|
|
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
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68001038300
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
LABETALOL 300 MG TABLET [10375]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68001038300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J1920
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$34.00
|
| Rate for Payer: AlohaCare Medicaid |
$17.00
|
| Rate for Payer: AlohaCare Medicare |
$10.54
|
| Rate for Payer: AlohaCare Medicare |
$4.03
|
| Rate for Payer: AlohaCare Medicare |
$21.08
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Devoted Health Medicare |
$23.12
|
| Rate for Payer: Devoted Health Medicare |
$11.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.54
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.60
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Humana Medicare |
$4.03
|
| Rate for Payer: Humana Medicare |
$10.54
|
| Rate for Payer: Humana Medicare |
$21.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.08
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.08
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
| Rate for Payer: University Health Alliance Commercial |
$24.78
|
| Rate for Payer: University Health Alliance Commercial |
$49.57
|
|
|
LABETALOL 5 MG/ML INTRAVENOUS SOLUTION [10372]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS J1920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.80 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 60687068711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 60687068757
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$4.03
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$4.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.03
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.03
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 60687068757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00904724568
|
|
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
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 60687068711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$4.03
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$4.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.03
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.03
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
LACOSAMIDE 100 MG TABLET [96969]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00904724568
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
LACOSAMIDE (10 MG/ML) ORAL SOLN SYRINGE [4080286]
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 00004080068
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Health Management Network Commercial |
$47.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: MDX Hawaii PPO |
$54.32
|
|
