|
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION [4995]
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS J1010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicaid |
$74.00
|
| Rate for Payer: AlohaCare Medicare |
$45.88
|
| Rate for Payer: AlohaCare Medicare |
$39.99
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Devoted Health Medicare |
$43.86
|
| Rate for Payer: Devoted Health Medicare |
$50.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$140.60
|
| Rate for Payer: Health Management Network Commercial |
$125.80
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Humana Medicare |
$39.99
|
| Rate for Payer: Humana Medicare |
$45.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.88
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: MDX Hawaii PPO |
$143.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.88
|
| Rate for Payer: University Health Alliance Commercial |
$94.03
|
| Rate for Payer: University Health Alliance Commercial |
$107.88
|
|
|
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J1010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION [4996]
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS J1010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$15.19
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$16.66
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$15.19
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION [10581]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$22.63
|
| Rate for Payer: AlohaCare Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$22.44
|
| Rate for Payer: Devoted Health Medicare |
$24.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Humana Medicare |
$20.46
|
| Rate for Payer: Humana Medicare |
$22.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.63
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.63
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
|
|
METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION [10581]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
METHYLPREDNISOLONE SOD SUCC 500 MG/8ML BWFI IJ (WET SOLR VIAL) [43010581]
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS J2930
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
METHYLPREDNISOLONE SOD SUCC 500 MG/8ML BWFI IJ (WET SOLR VIAL) [43010581]
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS J2930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$22.63
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$24.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$22.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.63
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.63
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION [191023]
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: AlohaCare Medicaid |
$83.00
|
| Rate for Payer: AlohaCare Medicare |
$51.46
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Devoted Health Medicare |
$56.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$157.70
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Humana Medicare |
$51.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.46
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$99.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.46
|
| Rate for Payer: University Health Alliance Commercial |
$121.00
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION [191023]
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.10 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [191021]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$9.92
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$10.54
|
| Rate for Payer: Devoted Health Medicare |
$10.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Humana Medicare |
$9.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.92
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.92
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION [191021]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION [191020]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
|
METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION [191020]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS J2919
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: AlohaCare Medicaid |
$12.00
|
| Rate for Payer: AlohaCare Medicare |
$7.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Devoted Health Medicare |
$8.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Humana Medicare |
$7.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.44
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.44
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
|
|
METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM [21507]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00883000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM [21507]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00883000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51079088801
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 51079088820
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51079088820
|
|
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
|
|
|
METOCLOPRAMIDE 10 MG TABLET [5005]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 51079088801
|
|
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
|
|
|
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77710]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00121157610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION [77710]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 00121057616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J2765
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION [5002]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2765
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687062011
|
|
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
|
|
|
METOCLOPRAMIDE 5 MG TABLET [5006]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687062011
|
|
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
|
|
