|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687073611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 35573042851
|
|
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
|
|
|
PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE [26225]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687073609
|
|
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
|
|
|
PANTOPRAZOLE 80 MG/250 ML IN NS (SIMPLE) [4080132]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00004080030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 55150020210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
PANTOPRAZOLE SODIUM 40 MG/10ML IV (WET SOLR VIAL) [43026226]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00143928410
|
|
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
|
|
|
PANTOPRAZOLE TABLETS (PROTONIX) 40 MG (TAKE HOME) [4080386]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080174
|
|
Hospital Revenue Code
|
253
|
| 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
|
|
|
PANTOPRAZOLE TABLETS (PROTONIX) 40 MG (TAKE HOME) [4080386]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080174
|
|
Hospital Revenue Code
|
253
|
| 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
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
NDC 54288014210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$95.06 |
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Health Management Network Commercial |
$83.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.20
|
| Rate for Payer: MDX Hawaii PPO |
$95.06
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
NDC 54288014201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$95.06 |
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Health Management Network Commercial |
$83.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.20
|
| Rate for Payer: MDX Hawaii PPO |
$95.06
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
NDC 14789012105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
NDC 14789012107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.05 |
| Max. Negotiated Rate |
$109.61 |
| Rate for Payer: Cash Price |
$67.80
|
| Rate for Payer: Health Management Network Commercial |
$96.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.70
|
| Rate for Payer: MDX Hawaii PPO |
$109.61
|
|
|
PAPAVERINE 30 MG/ML INJECTION SOLUTION [6030]
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
NDC 00517400225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
NDC 49483068703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.44 |
| 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: Devoted Health Medicare |
$8.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.44
|
| 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 Medicare |
$7.44
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
|
|
PARICALCITOL 1 MCG CAPSULE [41497]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 49483068703
|
|
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
|
|
|
PARIETEX PLUG
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$222.88 |
| Max. Negotiated Rate |
$386.06 |
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$278.60
|
| Rate for Payer: Health Management Network Commercial |
$338.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$358.20
|
| Rate for Payer: MDX Hawaii PPO |
$386.06
|
| Rate for Payer: University Health Alliance Commercial |
$222.88
|
|
|
PARIETEX PLUG
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$123.38 |
| Max. Negotiated Rate |
$386.06 |
| Rate for Payer: AlohaCare Medicaid |
$199.00
|
| Rate for Payer: AlohaCare Medicare |
$123.38
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Devoted Health Medicare |
$135.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$123.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$278.60
|
| Rate for Payer: Health Management Network Commercial |
$338.30
|
| Rate for Payer: Humana Medicare |
$123.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$358.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$202.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$123.38
|
| Rate for Payer: MDX Hawaii PPO |
$386.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$123.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$123.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$123.38
|
| Rate for Payer: University Health Alliance Commercial |
$222.88
|
|
|
PAROXETINE 10 MG TABLET [16632]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 68382009706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
PAROXETINE 10 MG TABLET [16632]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 68382009706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
PAROXETINE 20 MG TABLET [10855]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 68382009806
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
PAROXETINE 20 MG TABLET [10855]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 68084004501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
PAROXETINE 20 MG TABLET [10855]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 68084004501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
PAROXETINE 20 MG TABLET [10855]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 68382009806
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
PATCH WITTMANN EWP 2040
|
Facility
|
OP
|
$16,200.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,022.00 |
| Max. Negotiated Rate |
$15,714.00 |
| Rate for Payer: AlohaCare Medicaid |
$8,100.00
|
| Rate for Payer: AlohaCare Medicare |
$5,022.00
|
| Rate for Payer: Cash Price |
$9,720.00
|
| Rate for Payer: Devoted Health Medicare |
$5,508.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,022.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,390.00
|
| Rate for Payer: Health Management Network Commercial |
$13,770.00
|
| Rate for Payer: Humana Medicare |
$5,022.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,580.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,262.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,022.00
|
| Rate for Payer: MDX Hawaii PPO |
$15,714.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,022.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,022.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,022.00
|
| Rate for Payer: University Health Alliance Commercial |
$11,808.18
|
|
|
PATCH WITTMANN EWP 2040
|
Facility
|
IP
|
$16,200.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13,770.00 |
| Max. Negotiated Rate |
$15,714.00 |
| Rate for Payer: Cash Price |
$9,720.00
|
| Rate for Payer: Health Management Network Commercial |
$13,770.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,580.00
|
| Rate for Payer: MDX Hawaii PPO |
$15,714.00
|
|
