|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687045401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
TRAZODONE 100 MG TABLET [8083]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904686961
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
|
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
|
|
|
TRAZODONE 50 MG TABLET [8085]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904686861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
TREK RX 3.5X30
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$117.80 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: AlohaCare Medicaid |
$190.00
|
| Rate for Payer: AlohaCare Medicare |
$117.80
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Devoted Health Medicare |
$129.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$117.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Humana Medicare |
$117.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$193.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$117.80
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$117.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$117.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$117.80
|
| Rate for Payer: University Health Alliance Commercial |
$276.98
|
|
|
TREK RX 3.5X30
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$323.00 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
|
|
TREK RX 4X30
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$117.80 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: AlohaCare Medicaid |
$190.00
|
| Rate for Payer: AlohaCare Medicare |
$117.80
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Devoted Health Medicare |
$129.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$117.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Humana Medicare |
$117.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$193.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$117.80
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$117.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$117.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$117.80
|
| Rate for Payer: University Health Alliance Commercial |
$276.98
|
|
|
TREK RX 4X30
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$323.00 |
| Max. Negotiated Rate |
$368.60 |
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$323.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.00
|
| Rate for Payer: MDX Hawaii PPO |
$368.60
|
|
|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [188830]
|
Facility
|
OP
|
$50,165.00
|
|
|
Service Code
|
HCPCS J9347
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.17 |
| Max. Negotiated Rate |
$48,660.05 |
| Rate for Payer: AlohaCare Medicaid |
$25,082.50
|
| Rate for Payer: AlohaCare Medicaid |
$3,809.50
|
| Rate for Payer: AlohaCare Medicaid |
$6,458.50
|
| Rate for Payer: AlohaCare Medicare |
$2,361.89
|
| Rate for Payer: AlohaCare Medicare |
$15,551.15
|
| Rate for Payer: AlohaCare Medicare |
$4,004.27
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Devoted Health Medicare |
$2,590.46
|
| Rate for Payer: Devoted Health Medicare |
$4,391.78
|
| Rate for Payer: Devoted Health Medicare |
$17,056.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$179.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,361.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,004.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15,551.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$141.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$141.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,271.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,238.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47,656.75
|
| Rate for Payer: Health Management Network Commercial |
$10,979.45
|
| Rate for Payer: Health Management Network Commercial |
$6,476.15
|
| Rate for Payer: Health Management Network Commercial |
$42,640.25
|
| Rate for Payer: Humana Medicare |
$2,361.89
|
| Rate for Payer: Humana Medicare |
$15,551.15
|
| Rate for Payer: Humana Medicare |
$4,004.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,857.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$45,148.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,625.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25,584.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,587.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,885.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,004.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$15,551.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,361.89
|
| Rate for Payer: MDX Hawaii PPO |
$7,390.43
|
| Rate for Payer: MDX Hawaii PPO |
$12,529.49
|
| Rate for Payer: MDX Hawaii PPO |
$48,660.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,004.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15,551.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,361.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,361.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$15,551.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,004.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,750.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30,099.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,571.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$15,551.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,004.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,361.89
|
| Rate for Payer: University Health Alliance Commercial |
$36,565.27
|
| Rate for Payer: University Health Alliance Commercial |
$5,553.49
|
| Rate for Payer: University Health Alliance Commercial |
$9,415.20
|
|
|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [188830]
|
Facility
|
IP
|
$7,619.00
|
|
|
Service Code
|
HCPCS J9347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,476.15 |
| Max. Negotiated Rate |
$7,390.43 |
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Health Management Network Commercial |
$6,476.15
|
| Rate for Payer: Health Management Network Commercial |
$42,640.25
|
| Rate for Payer: Health Management Network Commercial |
$10,979.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,625.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$45,148.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,857.10
|
| Rate for Payer: MDX Hawaii PPO |
$48,660.05
|
| Rate for Payer: MDX Hawaii PPO |
$12,529.49
|
| Rate for Payer: MDX Hawaii PPO |
$7,390.43
|
|
|
TRIALTHON INSERT 5531-G-709-E
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
TRIALTHON INSERT 5531-G-709-E
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$829.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,338.00
|
| Rate for Payer: AlohaCare Medicare |
$829.56
|
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Devoted Health Medicare |
$909.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$829.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Humana Medicare |
$829.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,364.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$829.56
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$829.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$829.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$829.56
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
TRIALYSIS CATH TRAY 13FR 20CM
|
Facility
|
IP
|
$724.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$615.40 |
| Max. Negotiated Rate |
$702.28 |
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Health Management Network Commercial |
$615.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$651.60
|
| Rate for Payer: MDX Hawaii PPO |
$702.28
|
|
|
TRIALYSIS CATH TRAY 13FR 20CM
|
Facility
|
OP
|
$724.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$224.44 |
| Max. Negotiated Rate |
$702.28 |
| Rate for Payer: AlohaCare Medicaid |
$362.00
|
| Rate for Payer: AlohaCare Medicare |
$224.44
|
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Devoted Health Medicare |
$246.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$224.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$687.80
|
| Rate for Payer: Health Management Network Commercial |
$615.40
|
| Rate for Payer: Humana Medicare |
$224.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$651.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$369.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$224.44
|
| Rate for Payer: MDX Hawaii PPO |
$702.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$224.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$224.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$224.44
|
| Rate for Payer: University Health Alliance Commercial |
$527.72
|
|
|
TRIAMCINOLONE 0.1% CREAM (KENALOG) (15 GRAM) (TAKE HOME) [4080399]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080188
|
|
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
|
|
|
TRIAMCINOLONE 0.1% CREAM (KENALOG) (15 GRAM) (TAKE HOME) [4080399]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080188
|
|
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
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
NDC 64980032005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.80
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
NDC 51672126705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.62 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: AlohaCare Medicaid |
$101.00
|
| Rate for Payer: AlohaCare Medicare |
$62.62
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Devoted Health Medicare |
$68.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.90
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Humana Medicare |
$62.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.62
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.62
|
| Rate for Payer: University Health Alliance Commercial |
$147.24
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
NDC 51672126705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.80
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
NDC 64980032005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.62 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: AlohaCare Medicaid |
$101.00
|
| Rate for Payer: AlohaCare Medicare |
$62.62
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Devoted Health Medicare |
$68.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.90
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Humana Medicare |
$62.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.62
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.62
|
| Rate for Payer: University Health Alliance Commercial |
$147.24
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
NDC 42571038519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.75 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$283.50
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
NDC 00713067653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.75 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$283.50
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
NDC 42571038519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.65 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: AlohaCare Medicaid |
$157.50
|
| Rate for Payer: AlohaCare Medicare |
$97.65
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Devoted Health Medicare |
$107.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$97.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$299.25
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: Humana Medicare |
$97.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$283.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$160.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$97.65
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$97.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$97.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$97.65
|
| Rate for Payer: University Health Alliance Commercial |
$229.60
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
NDC 00713067653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.65 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: AlohaCare Medicaid |
$157.50
|
| Rate for Payer: AlohaCare Medicare |
$97.65
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Devoted Health Medicare |
$107.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$97.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$299.25
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: Humana Medicare |
$97.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$283.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$160.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$97.65
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$97.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$97.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$97.65
|
| Rate for Payer: University Health Alliance Commercial |
$229.60
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 45802006435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
