|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$28.16
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$27.88 |
| Rate for Payer: AlohaCare Medicaid |
$14.08
|
| Rate for Payer: AlohaCare Medicaid |
$6.71
|
| Rate for Payer: AlohaCare Medicare |
$12.08
|
| Rate for Payer: AlohaCare Medicare |
$25.34
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Devoted Health Medicare |
$13.29
|
| Rate for Payer: Devoted Health Medicare |
$27.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.75
|
| Rate for Payer: Health Management Network Commercial |
$11.41
|
| Rate for Payer: Health Management Network Commercial |
$23.94
|
| Rate for Payer: Humana Medicare |
$12.08
|
| Rate for Payer: Humana Medicare |
$25.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$27.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.08
|
| Rate for Payer: University Health Alliance Commercial |
$9.78
|
| Rate for Payer: University Health Alliance Commercial |
$20.53
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$13.42
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$13.02 |
| Rate for Payer: Cash Price |
$8.72
|
| Rate for Payer: Cash Price |
$18.30
|
| Rate for Payer: Health Management Network Commercial |
$23.94
|
| Rate for Payer: Health Management Network Commercial |
$11.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$27.32
|
|
|
BUPRENORPHINE HCL 2 MG SL SUBL.TAB
|
Facility
|
OP
|
$2.95
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: AlohaCare Medicaid |
$1.48
|
| Rate for Payer: AlohaCare Medicaid |
$6.76
|
| Rate for Payer: AlohaCare Medicare |
$2.65
|
| Rate for Payer: AlohaCare Medicare |
$12.18
|
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Devoted Health Medicare |
$13.39
|
| Rate for Payer: Devoted Health Medicare |
$2.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.85
|
| Rate for Payer: Health Management Network Commercial |
$2.51
|
| Rate for Payer: Health Management Network Commercial |
$11.50
|
| Rate for Payer: Humana Medicare |
$12.18
|
| Rate for Payer: Humana Medicare |
$2.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.18
|
| Rate for Payer: MDX Hawaii PPO |
$2.86
|
| Rate for Payer: MDX Hawaii PPO |
$13.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.65
|
| Rate for Payer: University Health Alliance Commercial |
$9.86
|
| Rate for Payer: University Health Alliance Commercial |
$2.15
|
|
|
BUPRENORPHINE HCL 2 MG SL SUBL.TAB
|
Facility
|
IP
|
$2.95
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$2.86 |
| Rate for Payer: Cash Price |
$1.92
|
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Health Management Network Commercial |
$11.50
|
| Rate for Payer: Health Management Network Commercial |
$2.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.65
|
| Rate for Payer: MDX Hawaii PPO |
$2.86
|
| Rate for Payer: MDX Hawaii PPO |
$13.12
|
|
|
BUPRENORPHINE HCL 8 MG SL SUBL.TAB
|
Facility
|
OP
|
$47.04
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$46.57 |
| Rate for Payer: AlohaCare Medicaid |
$23.52
|
| Rate for Payer: AlohaCare Medicaid |
$11.60
|
| Rate for Payer: AlohaCare Medicare |
$42.34
|
| Rate for Payer: AlohaCare Medicare |
$20.87
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Cash Price |
$30.58
|
| Rate for Payer: Devoted Health Medicare |
$22.96
|
| Rate for Payer: Devoted Health Medicare |
$46.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.03
|
| Rate for Payer: Health Management Network Commercial |
$39.98
|
| Rate for Payer: Health Management Network Commercial |
$19.71
|
| Rate for Payer: Humana Medicare |
$20.87
|
| Rate for Payer: Humana Medicare |
$42.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.87
|
| Rate for Payer: MDX Hawaii PPO |
$45.63
|
| Rate for Payer: MDX Hawaii PPO |
$22.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.34
|
| Rate for Payer: University Health Alliance Commercial |
$16.90
|
| Rate for Payer: University Health Alliance Commercial |
$34.29
|
|
|
BUPRENORPHINE HCL 8 MG SL SUBL.TAB
|
Facility
|
IP
|
$47.04
|
|
|
Service Code
|
HCPCS J0571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.98 |
| Max. Negotiated Rate |
$45.63 |
| Rate for Payer: Cash Price |
$30.58
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Health Management Network Commercial |
$19.71
|
| Rate for Payer: Health Management Network Commercial |
$39.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.34
|
| Rate for Payer: MDX Hawaii PPO |
$45.63
|
| Rate for Payer: MDX Hawaii PPO |
$22.49
|
|
|
BUPROPION 150 MG PO TAB EXTENDED RELEASE 24 HR (XL)
|
Facility
|
OP
|
$12.26
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.13 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: AlohaCare Medicaid |
$6.13
|
| Rate for Payer: AlohaCare Medicaid |
$12.64
|
| Rate for Payer: AlohaCare Medicare |
$11.03
|
| Rate for Payer: AlohaCare Medicare |
$22.76
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Devoted Health Medicare |
$12.14
|
| Rate for Payer: Devoted Health Medicare |
$25.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.65
|
| Rate for Payer: Health Management Network Commercial |
$10.42
|
| Rate for Payer: Health Management Network Commercial |
$21.50
|
| Rate for Payer: Humana Medicare |
$22.76
|
| Rate for Payer: Humana Medicare |
$11.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.03
|
| Rate for Payer: MDX Hawaii PPO |
$24.53
|
| Rate for Payer: MDX Hawaii PPO |
$11.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.76
|
| Rate for Payer: University Health Alliance Commercial |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$8.94
|
|
|
BUPROPION 150 MG PO TAB EXTENDED RELEASE 24 HR (XL)
|
Facility
|
IP
|
$25.29
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$24.53 |
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Health Management Network Commercial |
$21.50
|
| Rate for Payer: Health Management Network Commercial |
$10.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.03
|
| Rate for Payer: MDX Hawaii PPO |
$11.89
|
| Rate for Payer: MDX Hawaii PPO |
$24.53
|
|
|
BUPROPION HCL 100 MG PO SR12
|
Facility
|
OP
|
$10.71
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.36 |
| Max. Negotiated Rate |
$10.60 |
| Rate for Payer: AlohaCare Medicaid |
$5.36
|
| Rate for Payer: AlohaCare Medicaid |
$4.59
|
| Rate for Payer: AlohaCare Medicare |
$9.64
|
| Rate for Payer: AlohaCare Medicare |
$8.27
|
| Rate for Payer: Cash Price |
$5.97
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Devoted Health Medicare |
$10.60
|
| Rate for Payer: Devoted Health Medicare |
$9.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.17
|
| Rate for Payer: Health Management Network Commercial |
$9.10
|
| Rate for Payer: Health Management Network Commercial |
$7.81
|
| Rate for Payer: Humana Medicare |
$8.27
|
| Rate for Payer: Humana Medicare |
$9.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.64
|
| Rate for Payer: MDX Hawaii PPO |
$8.91
|
| Rate for Payer: MDX Hawaii PPO |
$10.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.27
|
| Rate for Payer: University Health Alliance Commercial |
$6.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.81
|
|
|
BUPROPION HCL 100 MG PO SR12
|
Facility
|
IP
|
$9.19
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$8.91 |
| Rate for Payer: Cash Price |
$5.97
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Health Management Network Commercial |
$7.81
|
| Rate for Payer: Health Management Network Commercial |
$9.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.64
|
| Rate for Payer: MDX Hawaii PPO |
$10.39
|
| Rate for Payer: MDX Hawaii PPO |
$8.91
|
|
|
BUPROPION HCL 150 MG PO SR12
|
Facility
|
IP
|
$10.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$10.36 |
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Health Management Network Commercial |
$9.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.61
|
| Rate for Payer: MDX Hawaii PPO |
$10.36
|
|
|
BUPROPION HCL 150 MG PO SR12
|
Facility
|
OP
|
$10.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$10.57 |
| Rate for Payer: AlohaCare Medicaid |
$5.34
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Devoted Health Medicare |
$10.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.15
|
| Rate for Payer: Health Management Network Commercial |
$9.08
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: MDX Hawaii PPO |
$10.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: University Health Alliance Commercial |
$7.78
|
|
|
BUPROPION HCL 200 MG PO SR12
|
Facility
|
IP
|
$18.65
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$18.09 |
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Health Management Network Commercial |
$15.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.79
|
| Rate for Payer: MDX Hawaii PPO |
$18.09
|
|
|
BUPROPION HCL 200 MG PO SR12
|
Facility
|
OP
|
$18.65
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$18.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.32
|
| Rate for Payer: AlohaCare Medicare |
$16.79
|
| Rate for Payer: Cash Price |
$12.12
|
| Rate for Payer: Devoted Health Medicare |
$18.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.72
|
| Rate for Payer: Health Management Network Commercial |
$15.85
|
| Rate for Payer: Humana Medicare |
$16.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.79
|
| Rate for Payer: MDX Hawaii PPO |
$18.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.79
|
| Rate for Payer: University Health Alliance Commercial |
$13.59
|
|
|
BUPROPION HCL 75 MG PO TABLET
|
Facility
|
IP
|
$7.27
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.18 |
| Max. Negotiated Rate |
$7.05 |
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Health Management Network Commercial |
$6.18
|
| Rate for Payer: Health Management Network Commercial |
$5.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.01
|
| Rate for Payer: MDX Hawaii PPO |
$6.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.05
|
|
|
BUPROPION HCL 75 MG PO TABLET
|
Facility
|
OP
|
$6.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$6.61 |
| Rate for Payer: AlohaCare Medicaid |
$3.34
|
| Rate for Payer: AlohaCare Medicaid |
$3.63
|
| Rate for Payer: AlohaCare Medicare |
$6.01
|
| Rate for Payer: AlohaCare Medicare |
$6.54
|
| Rate for Payer: Cash Price |
$4.73
|
| Rate for Payer: Cash Price |
$4.34
|
| Rate for Payer: Devoted Health Medicare |
$6.61
|
| Rate for Payer: Devoted Health Medicare |
$7.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.35
|
| Rate for Payer: Health Management Network Commercial |
$5.68
|
| Rate for Payer: Health Management Network Commercial |
$6.18
|
| Rate for Payer: Humana Medicare |
$6.54
|
| Rate for Payer: Humana Medicare |
$6.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.01
|
| Rate for Payer: MDX Hawaii PPO |
$7.05
|
| Rate for Payer: MDX Hawaii PPO |
$6.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.54
|
| Rate for Payer: University Health Alliance Commercial |
$5.30
|
| Rate for Payer: University Health Alliance Commercial |
$4.87
|
|
|
BUSPIRONE 10 MG PO TABLET
|
Facility
|
OP
|
$7.43
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.71 |
| Max. Negotiated Rate |
$7.36 |
| Rate for Payer: AlohaCare Medicaid |
$3.71
|
| Rate for Payer: AlohaCare Medicare |
$6.69
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Devoted Health Medicare |
$7.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.06
|
| Rate for Payer: Health Management Network Commercial |
$6.32
|
| Rate for Payer: Humana Medicare |
$6.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.69
|
| Rate for Payer: MDX Hawaii PPO |
$7.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.69
|
| Rate for Payer: University Health Alliance Commercial |
$5.42
|
|
|
BUSPIRONE 10 MG PO TABLET
|
Facility
|
IP
|
$7.43
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$7.21 |
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Health Management Network Commercial |
$6.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.69
|
| Rate for Payer: MDX Hawaii PPO |
$7.21
|
|
|
BUSPIRONE 5 MG PO TABLET
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Health Management Network Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.83
|
| Rate for Payer: MDX Hawaii PPO |
$4.13
|
|
|
BUSPIRONE 5 MG PO TABLET
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.13 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: AlohaCare Medicaid |
$2.13
|
| Rate for Payer: AlohaCare Medicare |
$3.83
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Devoted Health Medicare |
$4.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.05
|
| Rate for Payer: Health Management Network Commercial |
$3.62
|
| Rate for Payer: Humana Medicare |
$3.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.83
|
| Rate for Payer: MDX Hawaii PPO |
$4.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.83
|
| Rate for Payer: University Health Alliance Commercial |
$3.11
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG PO TABLET
|
Facility
|
OP
|
$9.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$9.23 |
| Rate for Payer: AlohaCare Medicaid |
$4.66
|
| Rate for Payer: AlohaCare Medicare |
$8.39
|
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Devoted Health Medicare |
$9.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.85
|
| Rate for Payer: Health Management Network Commercial |
$7.92
|
| Rate for Payer: Humana Medicare |
$8.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.39
|
| Rate for Payer: MDX Hawaii PPO |
$9.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.39
|
| Rate for Payer: University Health Alliance Commercial |
$6.79
|
|
|
BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG PO TABLET
|
Facility
|
IP
|
$9.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$9.04 |
| Rate for Payer: Cash Price |
$6.06
|
| Rate for Payer: Health Management Network Commercial |
$7.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.39
|
| Rate for Payer: MDX Hawaii PPO |
$9.04
|
|
|
BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOP AERO.SPRAY
|
Facility
|
OP
|
$442.54
|
|
|
Service Code
|
NDC 10223020104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$221.27 |
| Max. Negotiated Rate |
$438.11 |
| Rate for Payer: AlohaCare Medicaid |
$221.27
|
| Rate for Payer: AlohaCare Medicare |
$398.29
|
| Rate for Payer: Cash Price |
$287.65
|
| Rate for Payer: Devoted Health Medicare |
$438.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$398.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$420.41
|
| Rate for Payer: Health Management Network Commercial |
$376.16
|
| Rate for Payer: Humana Medicare |
$398.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$398.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$225.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$398.29
|
| Rate for Payer: MDX Hawaii PPO |
$429.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$398.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$398.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$265.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$398.29
|
| Rate for Payer: University Health Alliance Commercial |
$322.57
|
|
|
BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOP AERO.SPRAY
|
Facility
|
IP
|
$442.54
|
|
|
Service Code
|
NDC 10223020104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$376.16 |
| Max. Negotiated Rate |
$429.26 |
| Rate for Payer: Cash Price |
$287.65
|
| Rate for Payer: Health Management Network Commercial |
$376.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$398.29
|
| Rate for Payer: MDX Hawaii PPO |
$429.26
|
|
|
CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) IV SOLN
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
HCPCS J0706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.53 |
| Max. Negotiated Rate |
$65.65 |
| Rate for Payer: Cash Price |
$43.99
|
| Rate for Payer: Health Management Network Commercial |
$57.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.91
|
| Rate for Payer: MDX Hawaii PPO |
$65.65
|
|
