|
ketoconazole 2% cream topical 60 gm [HHSC]
|
Facility
|
IP
|
$375.80
|
|
|
Service Code
|
NDC 00168009960
|
| Hospital Charge Code |
2500437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$319.43 |
| Max. Negotiated Rate |
$364.53 |
| Rate for Payer: Cash Price |
$244.27
|
| Rate for Payer: Health Management Network Commercial |
$319.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$338.22
|
| Rate for Payer: MDX Hawaii PPO |
$364.53
|
|
|
ketoconazole 2% cream topical 60 gm [HHSC]
|
Facility
|
OP
|
$820.85
|
|
|
Service Code
|
NDC 51672129803
|
| Hospital Charge Code |
2500437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$410.43 |
| Max. Negotiated Rate |
$796.22 |
| Rate for Payer: AlohaCare Medicaid |
$410.43
|
| Rate for Payer: AlohaCare Medicare |
$410.43
|
| Rate for Payer: Cash Price |
$533.55
|
| Rate for Payer: Devoted Health Medicare |
$451.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$410.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$779.81
|
| Rate for Payer: Health Management Network Commercial |
$697.72
|
| Rate for Payer: Humana Medicare |
$410.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$738.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$418.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$410.43
|
| Rate for Payer: MDX Hawaii PPO |
$796.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$410.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$410.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$492.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$410.43
|
| Rate for Payer: University Health Alliance Commercial |
$598.32
|
|
|
ketoconazole 2% cream topical 60 gm [HHSC]
|
Facility
|
IP
|
$820.85
|
|
|
Service Code
|
NDC 51672129803
|
| Hospital Charge Code |
2500437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$697.72 |
| Max. Negotiated Rate |
$796.22 |
| Rate for Payer: Cash Price |
$533.55
|
| Rate for Payer: Health Management Network Commercial |
$697.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$738.76
|
| Rate for Payer: MDX Hawaii PPO |
$796.22
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
IP
|
$106.35
|
|
|
Service Code
|
NDC 61314012605
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.40 |
| Max. Negotiated Rate |
$103.16 |
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: Health Management Network Commercial |
$90.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.72
|
| Rate for Payer: MDX Hawaii PPO |
$103.16
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
OP
|
$107.49
|
|
|
Service Code
|
NDC 60505100301
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.74 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: AlohaCare Medicaid |
$53.74
|
| Rate for Payer: AlohaCare Medicare |
$53.74
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Devoted Health Medicare |
$59.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.12
|
| Rate for Payer: Health Management Network Commercial |
$91.37
|
| Rate for Payer: Humana Medicare |
$53.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.74
|
| Rate for Payer: MDX Hawaii PPO |
$104.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.74
|
| Rate for Payer: University Health Alliance Commercial |
$78.35
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
IP
|
$107.49
|
|
|
Service Code
|
NDC 60505100301
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.37 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Health Management Network Commercial |
$91.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.74
|
| Rate for Payer: MDX Hawaii PPO |
$104.27
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
NDC 47335022090
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.50 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: AlohaCare Medicaid |
$53.50
|
| Rate for Payer: AlohaCare Medicare |
$53.50
|
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Devoted Health Medicare |
$58.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.65
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Humana Medicare |
$53.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.50
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.50
|
| Rate for Payer: University Health Alliance Commercial |
$77.99
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
IP
|
$107.49
|
|
|
Service Code
|
NDC 17478020910
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.37 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Health Management Network Commercial |
$91.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.74
|
| Rate for Payer: MDX Hawaii PPO |
$104.27
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
OP
|
$107.49
|
|
|
Service Code
|
NDC 17478020910
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.74 |
| Max. Negotiated Rate |
$104.27 |
| Rate for Payer: AlohaCare Medicaid |
$53.74
|
| Rate for Payer: AlohaCare Medicare |
$53.74
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Devoted Health Medicare |
$59.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$102.12
|
| Rate for Payer: Health Management Network Commercial |
$91.37
|
| Rate for Payer: Humana Medicare |
$53.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.74
|
| Rate for Payer: MDX Hawaii PPO |
$104.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.74
|
| Rate for Payer: University Health Alliance Commercial |
$78.35
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
IP
|
$106.35
|
|
|
Service Code
|
NDC 70512079005
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.40 |
| Max. Negotiated Rate |
$103.16 |
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: Health Management Network Commercial |
$90.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.72
|
| Rate for Payer: MDX Hawaii PPO |
$103.16
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
OP
|
$106.77
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.38 |
| Max. Negotiated Rate |
$103.57 |
| Rate for Payer: AlohaCare Medicaid |
$53.38
|
| Rate for Payer: AlohaCare Medicare |
$53.38
|
| Rate for Payer: Cash Price |
$69.40
|
| Rate for Payer: Devoted Health Medicare |
$58.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.43
|
| Rate for Payer: Health Management Network Commercial |
$90.75
|
| Rate for Payer: Humana Medicare |
$53.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.38
|
| Rate for Payer: MDX Hawaii PPO |
$103.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.38
|
| Rate for Payer: University Health Alliance Commercial |
$77.82
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
OP
|
$106.35
|
|
|
Service Code
|
NDC 61314012605
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.17 |
| Max. Negotiated Rate |
$103.16 |
| Rate for Payer: AlohaCare Medicaid |
$53.17
|
| Rate for Payer: AlohaCare Medicare |
$53.17
|
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: Devoted Health Medicare |
$58.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.03
|
| Rate for Payer: Health Management Network Commercial |
$90.40
|
| Rate for Payer: Humana Medicare |
$53.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.17
|
| Rate for Payer: MDX Hawaii PPO |
$103.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.17
|
| Rate for Payer: University Health Alliance Commercial |
$77.52
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
IP
|
$106.77
|
|
|
Service Code
|
NDC 42571013725
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.75 |
| Max. Negotiated Rate |
$103.57 |
| Rate for Payer: Cash Price |
$69.40
|
| Rate for Payer: Health Management Network Commercial |
$90.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.09
|
| Rate for Payer: MDX Hawaii PPO |
$103.57
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
NDC 47335022090
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$69.55
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
ketorolac 0.5% ophth drops 5ml [HHSC]
|
Facility
|
OP
|
$106.35
|
|
|
Service Code
|
NDC 70512079005
|
| Hospital Charge Code |
2500440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.17 |
| Max. Negotiated Rate |
$103.16 |
| Rate for Payer: AlohaCare Medicaid |
$53.17
|
| Rate for Payer: AlohaCare Medicare |
$53.17
|
| Rate for Payer: Cash Price |
$69.13
|
| Rate for Payer: Devoted Health Medicare |
$58.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.03
|
| Rate for Payer: Health Management Network Commercial |
$90.40
|
| Rate for Payer: Humana Medicare |
$53.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.17
|
| Rate for Payer: MDX Hawaii PPO |
$103.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.17
|
| Rate for Payer: University Health Alliance Commercial |
$77.52
|
|
|
ketorolac 30 mg/ml vial [HHSC]
|
Facility
|
OP
|
$44.45
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2500438
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$43.12 |
| Rate for Payer: AlohaCare Medicaid |
$22.23
|
| Rate for Payer: AlohaCare Medicaid |
$2.33
|
| Rate for Payer: AlohaCare Medicaid |
$6.34
|
| Rate for Payer: AlohaCare Medicaid |
$3.73
|
| Rate for Payer: AlohaCare Medicaid |
$16.64
|
| Rate for Payer: AlohaCare Medicaid |
$5.84
|
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicare |
$16.64
|
| Rate for Payer: AlohaCare Medicare |
$6.34
|
| Rate for Payer: AlohaCare Medicare |
$2.33
|
| Rate for Payer: AlohaCare Medicare |
$5.84
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: AlohaCare Medicare |
$3.73
|
| Rate for Payer: AlohaCare Medicare |
$22.23
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cash Price |
$28.89
|
| Rate for Payer: Cash Price |
$28.89
|
| Rate for Payer: Devoted Health Medicare |
$6.42
|
| Rate for Payer: Devoted Health Medicare |
$24.45
|
| Rate for Payer: Devoted Health Medicare |
$4.11
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Devoted Health Medicare |
$6.97
|
| Rate for Payer: Devoted Health Medicare |
$18.31
|
| Rate for Payer: Devoted Health Medicare |
$2.57
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Health Management Network Commercial |
$37.78
|
| Rate for Payer: Health Management Network Commercial |
$28.30
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$6.35
|
| Rate for Payer: Health Management Network Commercial |
$10.78
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Health Management Network Commercial |
$3.97
|
| Rate for Payer: Humana Medicare |
$16.64
|
| Rate for Payer: Humana Medicare |
$3.73
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Humana Medicare |
$2.33
|
| Rate for Payer: Humana Medicare |
$6.34
|
| Rate for Payer: Humana Medicare |
$5.84
|
| Rate for Payer: Humana Medicare |
$22.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.84
|
| Rate for Payer: MDX Hawaii PPO |
$32.29
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$43.12
|
| Rate for Payer: MDX Hawaii PPO |
$4.53
|
| Rate for Payer: MDX Hawaii PPO |
$7.25
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
| Rate for Payer: MDX Hawaii PPO |
$12.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.34
|
| Rate for Payer: University Health Alliance Commercial |
$5.44
|
| Rate for Payer: University Health Alliance Commercial |
$32.40
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
| Rate for Payer: University Health Alliance Commercial |
$24.27
|
| Rate for Payer: University Health Alliance Commercial |
$9.24
|
| Rate for Payer: University Health Alliance Commercial |
$8.51
|
| Rate for Payer: University Health Alliance Commercial |
$3.40
|
|
|
ketorolac 30 mg/ml vial [HHSC]
|
Facility
|
IP
|
$44.45
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2500438
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.78 |
| Max. Negotiated Rate |
$43.12 |
| Rate for Payer: Cash Price |
$28.89
|
| Rate for Payer: Cash Price |
$21.64
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Cash Price |
$4.86
|
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Health Management Network Commercial |
$28.30
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Health Management Network Commercial |
$10.78
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$37.78
|
| Rate for Payer: Health Management Network Commercial |
$3.97
|
| Rate for Payer: Health Management Network Commercial |
$6.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: MDX Hawaii PPO |
$12.30
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$32.29
|
| Rate for Payer: MDX Hawaii PPO |
$7.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.53
|
| Rate for Payer: MDX Hawaii PPO |
$43.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
|
|
ketorolac 60 mg/2 mL vial [HHSC]
|
Facility
|
IP
|
$46.20
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2500439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.27 |
| Max. Negotiated Rate |
$44.81 |
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cash Price |
$12.49
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Health Management Network Commercial |
$16.34
|
| Rate for Payer: Health Management Network Commercial |
$39.27
|
| Rate for Payer: Health Management Network Commercial |
$5.84
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.18
|
| Rate for Payer: MDX Hawaii PPO |
$44.81
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: MDX Hawaii PPO |
$10.27
|
| Rate for Payer: MDX Hawaii PPO |
$18.64
|
| Rate for Payer: MDX Hawaii PPO |
$6.66
|
|
|
ketorolac 60 mg/2 mL vial [HHSC]
|
Facility
|
OP
|
$19.22
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2500439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$18.64 |
| Rate for Payer: AlohaCare Medicaid |
$9.61
|
| Rate for Payer: AlohaCare Medicaid |
$6.67
|
| Rate for Payer: AlohaCare Medicaid |
$3.44
|
| Rate for Payer: AlohaCare Medicaid |
$5.29
|
| Rate for Payer: AlohaCare Medicaid |
$23.10
|
| Rate for Payer: AlohaCare Medicare |
$3.44
|
| Rate for Payer: AlohaCare Medicare |
$6.67
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: AlohaCare Medicare |
$23.10
|
| Rate for Payer: AlohaCare Medicare |
$5.29
|
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$12.49
|
| Rate for Payer: Cash Price |
$12.49
|
| Rate for Payer: Cash Price |
$8.67
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cash Price |
$6.88
|
| Rate for Payer: Cash Price |
$4.47
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Devoted Health Medicare |
$5.82
|
| Rate for Payer: Devoted Health Medicare |
$10.57
|
| Rate for Payer: Devoted Health Medicare |
$3.78
|
| Rate for Payer: Devoted Health Medicare |
$25.41
|
| Rate for Payer: Devoted Health Medicare |
$7.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.06
|
| Rate for Payer: Health Management Network Commercial |
$16.34
|
| Rate for Payer: Health Management Network Commercial |
$11.34
|
| Rate for Payer: Health Management Network Commercial |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$39.27
|
| Rate for Payer: Health Management Network Commercial |
$5.84
|
| Rate for Payer: Humana Medicare |
$23.10
|
| Rate for Payer: Humana Medicare |
$3.44
|
| Rate for Payer: Humana Medicare |
$6.67
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Humana Medicare |
$5.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.44
|
| Rate for Payer: MDX Hawaii PPO |
$10.27
|
| Rate for Payer: MDX Hawaii PPO |
$18.64
|
| Rate for Payer: MDX Hawaii PPO |
$44.81
|
| Rate for Payer: MDX Hawaii PPO |
$6.66
|
| Rate for Payer: MDX Hawaii PPO |
$12.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.29
|
| Rate for Payer: University Health Alliance Commercial |
$7.72
|
| Rate for Payer: University Health Alliance Commercial |
$14.01
|
| Rate for Payer: University Health Alliance Commercial |
$9.72
|
| Rate for Payer: University Health Alliance Commercial |
$5.01
|
| Rate for Payer: University Health Alliance Commercial |
$33.68
|
|
|
ketorol-phenyleph 0.3%-1% oph 4mL [HHSC]
|
Facility
|
OP
|
$1,408.22
|
|
|
Service Code
|
NDC 62225060004
|
| Hospital Charge Code |
2500441
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$704.11 |
| Max. Negotiated Rate |
$1,365.97 |
| Rate for Payer: AlohaCare Medicaid |
$704.11
|
| Rate for Payer: AlohaCare Medicare |
$704.11
|
| Rate for Payer: Cash Price |
$915.34
|
| Rate for Payer: Devoted Health Medicare |
$774.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$704.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,337.81
|
| Rate for Payer: Health Management Network Commercial |
$1,196.99
|
| Rate for Payer: Humana Medicare |
$704.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,267.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$718.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$704.11
|
| Rate for Payer: MDX Hawaii PPO |
$1,365.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$704.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$704.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$844.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$704.11
|
| Rate for Payer: University Health Alliance Commercial |
$1,026.45
|
|
|
ketorol-phenyleph 0.3%-1% oph 4mL [HHSC]
|
Facility
|
IP
|
$1,408.22
|
|
|
Service Code
|
NDC 62225060010
|
| Hospital Charge Code |
2500441
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,196.99 |
| Max. Negotiated Rate |
$1,365.97 |
| Rate for Payer: Cash Price |
$915.34
|
| Rate for Payer: Health Management Network Commercial |
$1,196.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,267.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,365.97
|
|
|
ketorol-phenyleph 0.3%-1% oph 4mL [HHSC]
|
Facility
|
OP
|
$1,408.22
|
|
|
Service Code
|
NDC 62225060010
|
| Hospital Charge Code |
2500441
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$704.11 |
| Max. Negotiated Rate |
$1,365.97 |
| Rate for Payer: AlohaCare Medicaid |
$704.11
|
| Rate for Payer: AlohaCare Medicare |
$704.11
|
| Rate for Payer: Cash Price |
$915.34
|
| Rate for Payer: Devoted Health Medicare |
$774.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$704.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,337.81
|
| Rate for Payer: Health Management Network Commercial |
$1,196.99
|
| Rate for Payer: Humana Medicare |
$704.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,267.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$718.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$704.11
|
| Rate for Payer: MDX Hawaii PPO |
$1,365.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$704.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$704.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$844.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$704.11
|
| Rate for Payer: University Health Alliance Commercial |
$1,026.45
|
|
|
ketorol-phenyleph 0.3%-1% oph 4mL [HHSC]
|
Facility
|
IP
|
$1,408.22
|
|
|
Service Code
|
NDC 62225060004
|
| Hospital Charge Code |
2500441
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,196.99 |
| Max. Negotiated Rate |
$1,365.97 |
| Rate for Payer: Cash Price |
$915.34
|
| Rate for Payer: Health Management Network Commercial |
$1,196.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,267.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,365.97
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC
|
Facility
|
IP
|
$46,555.70
|
|
|
Service Code
|
MSDRG 657
|
| Min. Negotiated Rate |
$46,555.70 |
| Max. Negotiated Rate |
$46,555.70 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,555.70
|
|
|
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC
|
Facility
|
IP
|
$46,555.70
|
|
|
Service Code
|
MSDRG 656
|
| Min. Negotiated Rate |
$46,555.70 |
| Max. Negotiated Rate |
$46,555.70 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,555.70
|
|
