|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [39918]
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: AlohaCare Medicaid |
$19.50
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicaid |
$46.00
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicaid |
$46.50
|
| Rate for Payer: AlohaCare Medicare |
$28.83
|
| Rate for Payer: AlohaCare Medicare |
$12.09
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: AlohaCare Medicare |
$28.52
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$31.28
|
| Rate for Payer: Devoted Health Medicare |
$13.26
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Devoted Health Medicare |
$10.54
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Devoted Health Medicare |
$31.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$88.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Humana Medicare |
$28.52
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Humana Medicare |
$28.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.09
|
| Rate for Payer: University Health Alliance Commercial |
$67.06
|
| Rate for Payer: University Health Alliance Commercial |
$67.79
|
| Rate for Payer: University Health Alliance Commercial |
$28.43
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION [39918]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J3260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Health Management Network Commercial |
$79.05
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$90.21
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
IP
|
$626.00
|
|
|
Service Code
|
NDC 00078087601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$532.10 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
|
|
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT [11566]
|
Facility
|
OP
|
$626.00
|
|
|
Service Code
|
NDC 00078087601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.06 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: AlohaCare Medicaid |
$313.00
|
| Rate for Payer: AlohaCare Medicare |
$194.06
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Devoted Health Medicare |
$212.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$594.70
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Humana Medicare |
$194.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$319.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$194.06
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$194.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.06
|
| Rate for Payer: University Health Alliance Commercial |
$456.29
|
|
|
TOLNAFTATE 1 % TOPICAL POWDER [8021]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00536132926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 27241019230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR [29435]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 27241019230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$843.00
|
|
|
Service Code
|
NDC 49884076852
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$716.55 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
IP
|
$843.00
|
|
|
Service Code
|
NDC 31722086803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$716.55 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$843.00
|
|
|
Service Code
|
NDC 31722086803
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.33 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: AlohaCare Medicaid |
$421.50
|
| Rate for Payer: AlohaCare Medicare |
$261.33
|
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Devoted Health Medicare |
$286.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$261.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$800.85
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Humana Medicare |
$261.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$429.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$261.33
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$261.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$261.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$261.33
|
| Rate for Payer: University Health Alliance Commercial |
$614.46
|
|
|
TOLVAPTAN 15 MG TABLET [97893]
|
Facility
|
OP
|
$843.00
|
|
|
Service Code
|
NDC 49884076852
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$261.33 |
| Max. Negotiated Rate |
$817.71 |
| Rate for Payer: AlohaCare Medicaid |
$421.50
|
| Rate for Payer: AlohaCare Medicare |
$261.33
|
| Rate for Payer: Cash Price |
$505.80
|
| Rate for Payer: Devoted Health Medicare |
$286.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$261.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$800.85
|
| Rate for Payer: Health Management Network Commercial |
$716.55
|
| Rate for Payer: Humana Medicare |
$261.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$758.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$429.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$261.33
|
| Rate for Payer: MDX Hawaii PPO |
$817.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$261.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$261.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$261.33
|
| Rate for Payer: University Health Alliance Commercial |
$614.46
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084034401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084034401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 68084034411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.89 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
TOPIRAMATE 100 MG TABLET [18922]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 68084034411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 68382013814
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68084034211
|
|
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
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68084034201
|
|
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
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084034211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 68382013814
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084034201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]
|
Facility
|
IP
|
$779.00
|
|
|
Service Code
|
HCPCS J9351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$662.15 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: Cash Price |
$467.40
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Health Management Network Commercial |
$353.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$374.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$403.52
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]
|
Facility
|
OP
|
$779.00
|
|
|
Service Code
|
HCPCS J9351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$755.63 |
| Rate for Payer: AlohaCare Medicaid |
$389.50
|
| Rate for Payer: AlohaCare Medicaid |
$58.00
|
| Rate for Payer: AlohaCare Medicaid |
$208.00
|
| Rate for Payer: AlohaCare Medicare |
$128.96
|
| Rate for Payer: AlohaCare Medicare |
$35.96
|
| Rate for Payer: AlohaCare Medicare |
$241.49
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$467.40
|
| Rate for Payer: Cash Price |
$467.40
|
| Rate for Payer: Devoted Health Medicare |
$264.86
|
| Rate for Payer: Devoted Health Medicare |
$39.44
|
| Rate for Payer: Devoted Health Medicare |
$141.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$241.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$740.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$395.20
|
| Rate for Payer: Health Management Network Commercial |
$353.60
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Humana Medicare |
$35.96
|
| Rate for Payer: Humana Medicare |
$241.49
|
| Rate for Payer: Humana Medicare |
$128.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$374.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$701.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$397.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$241.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.96
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: MDX Hawaii PPO |
$403.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$241.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$241.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$249.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$467.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$241.49
|
| Rate for Payer: University Health Alliance Commercial |
$567.81
|
| Rate for Payer: University Health Alliance Commercial |
$84.55
|
| Rate for Payer: University Health Alliance Commercial |
$303.22
|
|
|
TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) INTRAVENOUS SOLUTION [195440]
|
Facility
|
OP
|
$11,928.00
|
|
|
Service Code
|
HCPCS J3263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.50 |
| Max. Negotiated Rate |
$11,570.16 |
| Rate for Payer: AlohaCare Medicaid |
$5,964.00
|
| Rate for Payer: AlohaCare Medicare |
$3,697.68
|
| Rate for Payer: Cash Price |
$7,156.80
|
| Rate for Payer: Cash Price |
$7,156.80
|
| Rate for Payer: Devoted Health Medicare |
$4,055.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$39.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$49.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,697.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$39.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,331.60
|
| Rate for Payer: Health Management Network Commercial |
$10,138.80
|
| Rate for Payer: Humana Medicare |
$3,697.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,735.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,083.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,697.68
|
| Rate for Payer: MDX Hawaii PPO |
$11,570.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,697.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,697.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,156.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,697.68
|
| Rate for Payer: University Health Alliance Commercial |
$8,694.32
|
|
|
TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) INTRAVENOUS SOLUTION [195440]
|
Facility
|
IP
|
$11,928.00
|
|
|
Service Code
|
HCPCS J3263
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,138.80 |
| Max. Negotiated Rate |
$11,570.16 |
| Rate for Payer: Cash Price |
$7,156.80
|
| Rate for Payer: Health Management Network Commercial |
$10,138.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,735.20
|
| Rate for Payer: MDX Hawaii PPO |
$11,570.16
|
|
