|
ZIPRASIDONE 20 MG CAPSULE [29778]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 68084010311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION [33175]
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
HCPCS J3486
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.14 |
| Max. Negotiated Rate |
$96.03 |
| Rate for Payer: AlohaCare Medicaid |
$49.50
|
| Rate for Payer: AlohaCare Medicare |
$30.69
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Devoted Health Medicare |
$33.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.05
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Humana Medicare |
$30.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.69
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.69
|
| Rate for Payer: University Health Alliance Commercial |
$72.16
|
|
|
ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION [33175]
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
HCPCS J3486
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.15 |
| Max. Negotiated Rate |
$96.03 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 68084010411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 50268081212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 68084010409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$8.06
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Humana Medicare |
$8.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.06
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.06
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 68001045106
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 68084010409
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 50268081212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 68001045106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
|
ZIPRASIDONE 40 MG CAPSULE [29779]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 68084010411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.06 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$8.06
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Humana Medicare |
$8.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.06
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.06
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
ZIPWIRE GLIDEWIRE M0066802061
|
Facility
|
IP
|
$183.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$155.55 |
| Max. Negotiated Rate |
$177.51 |
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Health Management Network Commercial |
$155.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.70
|
| Rate for Payer: MDX Hawaii PPO |
$177.51
|
|
|
ZIPWIRE GLIDEWIRE M0066802061
|
Facility
|
OP
|
$183.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.73 |
| Max. Negotiated Rate |
$177.51 |
| Rate for Payer: AlohaCare Medicaid |
$91.50
|
| Rate for Payer: AlohaCare Medicare |
$56.73
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Devoted Health Medicare |
$62.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$173.85
|
| Rate for Payer: Health Management Network Commercial |
$155.55
|
| Rate for Payer: Humana Medicare |
$56.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.73
|
| Rate for Payer: MDX Hawaii PPO |
$177.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.73
|
| Rate for Payer: University Health Alliance Commercial |
$133.39
|
|
|
ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION [117162]
|
Facility
|
OP
|
$2,880.00
|
|
|
Service Code
|
HCPCS J9400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$2,793.60 |
| Rate for Payer: AlohaCare Medicaid |
$1,440.00
|
| Rate for Payer: AlohaCare Medicaid |
$2,477.00
|
| Rate for Payer: AlohaCare Medicare |
$1,535.74
|
| Rate for Payer: AlohaCare Medicare |
$892.80
|
| Rate for Payer: Cash Price |
$2,972.40
|
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Cash Price |
$2,972.40
|
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Devoted Health Medicare |
$979.20
|
| Rate for Payer: Devoted Health Medicare |
$1,684.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,535.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$892.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,736.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,706.30
|
| Rate for Payer: Health Management Network Commercial |
$4,210.90
|
| Rate for Payer: Health Management Network Commercial |
$2,448.00
|
| Rate for Payer: Humana Medicare |
$892.80
|
| Rate for Payer: Humana Medicare |
$1,535.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,592.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,458.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,526.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,468.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$892.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,535.74
|
| Rate for Payer: MDX Hawaii PPO |
$2,793.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,805.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,535.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$892.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$892.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,535.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,972.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,728.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$892.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,535.74
|
| Rate for Payer: University Health Alliance Commercial |
$2,099.23
|
| Rate for Payer: University Health Alliance Commercial |
$3,610.97
|
|
|
ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) INTRAVENOUS SOLUTION [117162]
|
Facility
|
IP
|
$2,880.00
|
|
|
Service Code
|
HCPCS J9400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,448.00 |
| Max. Negotiated Rate |
$2,793.60 |
| Rate for Payer: Cash Price |
$1,728.00
|
| Rate for Payer: Cash Price |
$2,972.40
|
| Rate for Payer: Health Management Network Commercial |
$2,448.00
|
| Rate for Payer: Health Management Network Commercial |
$4,210.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,592.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,458.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,805.38
|
| Rate for Payer: MDX Hawaii PPO |
$2,793.60
|
|
|
ZIV-AFLIBERCEPT 200 MG/8 ML (25 MG/ML) INTRAVENOUS SOLUTION [117163]
|
Facility
|
IP
|
$4,954.00
|
|
|
Service Code
|
HCPCS J9400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,210.90 |
| Max. Negotiated Rate |
$4,805.38 |
| Rate for Payer: Cash Price |
$2,972.40
|
| Rate for Payer: Cash Price |
$3,456.00
|
| Rate for Payer: Health Management Network Commercial |
$4,210.90
|
| Rate for Payer: Health Management Network Commercial |
$4,896.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,458.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,184.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,587.20
|
| Rate for Payer: MDX Hawaii PPO |
$4,805.38
|
|
|
ZIV-AFLIBERCEPT 200 MG/8 ML (25 MG/ML) INTRAVENOUS SOLUTION [117163]
|
Facility
|
OP
|
$4,954.00
|
|
|
Service Code
|
HCPCS J9400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$4,805.38 |
| Rate for Payer: AlohaCare Medicaid |
$2,477.00
|
| Rate for Payer: AlohaCare Medicaid |
$2,880.00
|
| Rate for Payer: AlohaCare Medicare |
$1,785.60
|
| Rate for Payer: AlohaCare Medicare |
$1,535.74
|
| Rate for Payer: Cash Price |
$3,456.00
|
| Rate for Payer: Cash Price |
$2,972.40
|
| Rate for Payer: Cash Price |
$3,456.00
|
| Rate for Payer: Cash Price |
$2,972.40
|
| Rate for Payer: Devoted Health Medicare |
$1,684.36
|
| Rate for Payer: Devoted Health Medicare |
$1,958.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,785.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,535.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,706.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,472.00
|
| Rate for Payer: Health Management Network Commercial |
$4,896.00
|
| Rate for Payer: Health Management Network Commercial |
$4,210.90
|
| Rate for Payer: Humana Medicare |
$1,535.74
|
| Rate for Payer: Humana Medicare |
$1,785.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,458.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,184.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,937.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,526.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,535.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,785.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,805.38
|
| Rate for Payer: MDX Hawaii PPO |
$5,587.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,785.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,535.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,535.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,785.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,456.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,972.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,535.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,785.60
|
| Rate for Payer: University Health Alliance Commercial |
$3,610.97
|
| Rate for Payer: University Health Alliance Commercial |
$4,198.46
|
|
|
ZOLBETUXIMAB-CLZB 100 MG INTRAVENOUS SOLUTION [234229]
|
Facility
|
IP
|
$2,420.00
|
|
|
Service Code
|
NDC 00469342510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,057.00 |
| Max. Negotiated Rate |
$2,347.40 |
| Rate for Payer: Cash Price |
$1,452.00
|
| Rate for Payer: Health Management Network Commercial |
$2,057.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,178.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,347.40
|
|
|
ZOLBETUXIMAB-CLZB 300 MG INTRAVENOUS SOLUTION [235396]
|
Facility
|
IP
|
$6,260.00
|
|
|
Service Code
|
NDC 00469442530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,321.00 |
| Max. Negotiated Rate |
$6,072.20 |
| Rate for Payer: Cash Price |
$3,756.00
|
| Rate for Payer: Health Management Network Commercial |
$5,321.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,634.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,072.20
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]
|
Facility
|
IP
|
$1,062.00
|
|
|
Service Code
|
HCPCS J3489
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$902.70 |
| Max. Negotiated Rate |
$1,030.14 |
| Rate for Payer: Cash Price |
$637.20
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Health Management Network Commercial |
$902.70
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$955.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.50
|
| Rate for Payer: MDX Hawaii PPO |
$218.25
|
| Rate for Payer: MDX Hawaii PPO |
$1,030.14
|
|
|
ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION [35640]
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
HCPCS J3489
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: AlohaCare Medicaid |
$112.50
|
| Rate for Payer: AlohaCare Medicaid |
$531.00
|
| Rate for Payer: AlohaCare Medicare |
$329.22
|
| Rate for Payer: AlohaCare Medicare |
$69.75
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Cash Price |
$637.20
|
| Rate for Payer: Cash Price |
$637.20
|
| Rate for Payer: Cash Price |
$135.00
|
| Rate for Payer: Devoted Health Medicare |
$361.08
|
| Rate for Payer: Devoted Health Medicare |
$76.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$329.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.75
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$213.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,008.90
|
| Rate for Payer: Health Management Network Commercial |
$902.70
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Humana Medicare |
$69.75
|
| Rate for Payer: Humana Medicare |
$329.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$955.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$114.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$541.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$329.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.75
|
| Rate for Payer: MDX Hawaii PPO |
$218.25
|
| Rate for Payer: MDX Hawaii PPO |
$1,030.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$329.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$329.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$637.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$329.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.75
|
| Rate for Payer: University Health Alliance Commercial |
$164.00
|
| Rate for Payer: University Health Alliance Commercial |
$774.09
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]
|
Facility
|
IP
|
$1,470.00
|
|
|
Service Code
|
HCPCS J3489
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,249.50 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Health Management Network Commercial |
$535.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.00
|
| Rate for Payer: MDX Hawaii PPO |
$611.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
|
|
ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK [81434]
|
Facility
|
OP
|
$1,470.00
|
|
|
Service Code
|
HCPCS J3489
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: AlohaCare Medicaid |
$735.00
|
| Rate for Payer: AlohaCare Medicaid |
$315.00
|
| Rate for Payer: AlohaCare Medicare |
$195.30
|
| Rate for Payer: AlohaCare Medicare |
$455.70
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Devoted Health Medicare |
$499.80
|
| Rate for Payer: Devoted Health Medicare |
$214.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$195.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$455.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,396.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$598.50
|
| Rate for Payer: Health Management Network Commercial |
$535.50
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Humana Medicare |
$455.70
|
| Rate for Payer: Humana Medicare |
$195.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$321.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$749.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$455.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$195.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
| Rate for Payer: MDX Hawaii PPO |
$611.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$195.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$455.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$455.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$195.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$378.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$882.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$455.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$195.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,071.48
|
| Rate for Payer: University Health Alliance Commercial |
$459.21
|
|
|
ZOLMITRIPTAN 2.5 MG DISINTEGRATING TABLET [29868]
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
NDC 68382071569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
ZOLMITRIPTAN 2.5 MG DISINTEGRATING TABLET [29868]
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
NDC 68382071586
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.37 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$39.37
|
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Devoted Health Medicare |
$43.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.65
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$39.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.37
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.37
|
| Rate for Payer: University Health Alliance Commercial |
$92.57
|
|
