|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 00409420810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00409812610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
NDC 00409174910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
NDC 00409174929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [105634]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 00409420801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| 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: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| 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 Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J0665
|
|
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
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.15 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: AlohaCare Medicaid |
$29.50
|
| Rate for Payer: AlohaCare Medicare |
$18.29
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Devoted Health Medicare |
$20.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Humana Medicare |
$18.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.29
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.29
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [105639]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [105639]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Devoted Health Medicare |
$10.54
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: AlohaCare Medicare |
$4.03
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Humana Medicare |
$4.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.03
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.03
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J0665
|
|
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 |
$7.20
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$130.50
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: AlohaCare Medicaid |
$72.50
|
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$6.51
|
| Rate for Payer: AlohaCare Medicare |
$44.95
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$49.30
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$44.95
|
| Rate for Payer: Humana Medicare |
$6.51
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$130.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: University Health Alliance Commercial |
$105.69
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [122185]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| 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: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| 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 Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.03
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [122185]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J0665
|
|
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
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 60687062611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 60687062665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 60687062665
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET [34713]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 60687062611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687063711
|
|
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
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687063711
|
|
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
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 60687063765
|
|
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
|
|
|
BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET [34714]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 60687063765
|
|
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
|
|
