|
NAIL TROCHANTERIC 8130-0170S
|
Facility
|
OP
|
$5,248.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,626.88 |
| Max. Negotiated Rate |
$5,090.56 |
| Rate for Payer: AlohaCare Medicaid |
$2,624.00
|
| Rate for Payer: AlohaCare Medicare |
$1,626.88
|
| Rate for Payer: Cash Price |
$3,148.80
|
| Rate for Payer: Devoted Health Medicare |
$1,784.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,626.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,673.60
|
| Rate for Payer: Health Management Network Commercial |
$4,460.80
|
| Rate for Payer: Humana Medicare |
$1,626.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,723.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,676.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,626.88
|
| Rate for Payer: MDX Hawaii PPO |
$5,090.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,626.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,626.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,626.88
|
| Rate for Payer: University Health Alliance Commercial |
$2,938.88
|
|
|
NAIL TROCHANTERIC 8130-1170S
|
Facility
|
IP
|
$5,248.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,938.88 |
| Max. Negotiated Rate |
$5,090.56 |
| Rate for Payer: Cash Price |
$3,148.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,673.60
|
| Rate for Payer: Health Management Network Commercial |
$4,460.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,723.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,090.56
|
| Rate for Payer: University Health Alliance Commercial |
$2,938.88
|
|
|
NAIL TROCHANTERIC 8130-1170S
|
Facility
|
OP
|
$5,248.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,626.88 |
| Max. Negotiated Rate |
$5,090.56 |
| Rate for Payer: AlohaCare Medicaid |
$2,624.00
|
| Rate for Payer: AlohaCare Medicare |
$1,626.88
|
| Rate for Payer: Cash Price |
$3,148.80
|
| Rate for Payer: Devoted Health Medicare |
$1,784.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,626.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,673.60
|
| Rate for Payer: Health Management Network Commercial |
$4,460.80
|
| Rate for Payer: Humana Medicare |
$1,626.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,723.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,676.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,626.88
|
| Rate for Payer: MDX Hawaii PPO |
$5,090.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,626.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,626.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,626.88
|
| Rate for Payer: University Health Alliance Commercial |
$2,938.88
|
|
|
NAIL TROCHANTERIC 8130-2170S
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,482.11 |
| Max. Negotiated Rate |
$4,637.57 |
| Rate for Payer: AlohaCare Medicaid |
$2,390.50
|
| Rate for Payer: AlohaCare Medicare |
$1,482.11
|
| Rate for Payer: Cash Price |
$2,868.60
|
| Rate for Payer: Devoted Health Medicare |
$1,625.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,482.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,346.70
|
| Rate for Payer: Health Management Network Commercial |
$4,063.85
|
| Rate for Payer: Humana Medicare |
$1,482.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,302.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,438.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,482.11
|
| Rate for Payer: MDX Hawaii PPO |
$4,637.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,482.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,482.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,482.11
|
| Rate for Payer: University Health Alliance Commercial |
$2,677.36
|
|
|
NAIL TROCHANTERIC 8130-2170S
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,677.36 |
| Max. Negotiated Rate |
$4,637.57 |
| Rate for Payer: Cash Price |
$2,868.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,346.70
|
| Rate for Payer: Health Management Network Commercial |
$4,063.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,302.90
|
| Rate for Payer: MDX Hawaii PPO |
$4,637.57
|
| Rate for Payer: University Health Alliance Commercial |
$2,677.36
|
|
|
NAIL TROCHANTERIC 8130-3170S
|
Facility
|
IP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,677.36 |
| Max. Negotiated Rate |
$4,637.57 |
| Rate for Payer: Cash Price |
$2,868.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,346.70
|
| Rate for Payer: Health Management Network Commercial |
$4,063.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,302.90
|
| Rate for Payer: MDX Hawaii PPO |
$4,637.57
|
| Rate for Payer: University Health Alliance Commercial |
$2,677.36
|
|
|
NAIL TROCHANTERIC 8130-3170S
|
Facility
|
OP
|
$4,781.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,482.11 |
| Max. Negotiated Rate |
$4,637.57 |
| Rate for Payer: AlohaCare Medicaid |
$2,390.50
|
| Rate for Payer: AlohaCare Medicare |
$1,482.11
|
| Rate for Payer: Cash Price |
$2,868.60
|
| Rate for Payer: Devoted Health Medicare |
$1,625.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,482.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,346.70
|
| Rate for Payer: Health Management Network Commercial |
$4,063.85
|
| Rate for Payer: Humana Medicare |
$1,482.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,302.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,438.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,482.11
|
| Rate for Payer: MDX Hawaii PPO |
$4,637.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,482.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,482.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,482.11
|
| Rate for Payer: University Health Alliance Commercial |
$2,677.36
|
|
|
NAI TI 10X400/RT 04.003.360S
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,408.00 |
| Max. Negotiated Rate |
$4,171.00 |
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,010.00
|
| Rate for Payer: Health Management Network Commercial |
$3,655.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,870.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,171.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,408.00
|
|
|
NAI TI 10X400/RT 04.003.360S
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,333.00 |
| Max. Negotiated Rate |
$4,171.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,150.00
|
| Rate for Payer: AlohaCare Medicare |
$1,333.00
|
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Devoted Health Medicare |
$1,462.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,333.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,010.00
|
| Rate for Payer: Health Management Network Commercial |
$3,655.00
|
| Rate for Payer: Humana Medicare |
$1,333.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,870.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,193.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,333.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,171.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,333.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,333.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,333.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,408.00
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J2300
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
NALBUPHINE 10 MG/ML INJECTION SOLUTION [5339]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J2300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
NALOXONE 0.4 MG/10 ML (40 MCG/ML) DILUTE INJ (RN PREP) [401284]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| 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 |
$15.30
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
NALOXONE 0.4 MG/10 ML (40 MCG/ML) DILUTE INJ (RN PREP) [401284]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| 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 |
$15.30
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
NALOXONE 0.4 MG/ML INJECTION SOLUTION [5373]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
NALOXONE 1 MG/ML INJECTION SYRINGE [134075]
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
HCPCS J2312
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$96.03 |
| Rate for Payer: AlohaCare Medicaid |
$49.50
|
| Rate for Payer: AlohaCare Medicare |
$30.69
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Devoted Health Medicare |
$33.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.05
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Humana Medicare |
$30.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.69
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.69
|
| Rate for Payer: University Health Alliance Commercial |
$72.16
|
|
|
NALOXONE 1 MG/ML INJECTION SYRINGE [134075]
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
HCPCS J2312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.15 |
| Max. Negotiated Rate |
$96.03 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
|
|
NALOXONE 4 MG/ACTUATION NASAL SPRAY [131429]
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
NDC 45802057884
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$116.40 |
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Health Management Network Commercial |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.00
|
| Rate for Payer: MDX Hawaii PPO |
$116.40
|
|
|
NALOXONE 4 MG/ACTUATION NASAL SPRAY [131429]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 69547062702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.80 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 68084029111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00904703604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 47335032683
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 00406117003
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 47335032683
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
NALTREXONE 50 MG TABLET [10685]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 68084029111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
