|
ISOSORBIDE DINITRATE 10 MG PO TABLET
|
Facility
|
OP
|
$6.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$6.83 |
| Rate for Payer: AlohaCare Medicaid |
$3.45
|
| Rate for Payer: AlohaCare Medicare |
$6.21
|
| Rate for Payer: Cash Price |
$4.49
|
| Rate for Payer: Devoted Health Medicare |
$6.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.55
|
| Rate for Payer: Health Management Network Commercial |
$5.87
|
| Rate for Payer: Humana Medicare |
$6.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.21
|
| Rate for Payer: MDX Hawaii PPO |
$6.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.21
|
| Rate for Payer: University Health Alliance Commercial |
$5.03
|
|
|
ISOSORBIDE MONONITRATE 30 MG PO TAB SR 24H
|
Facility
|
OP
|
$2.10
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: AlohaCare Medicaid |
$1.05
|
| Rate for Payer: AlohaCare Medicare |
$1.89
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Devoted Health Medicare |
$2.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.00
|
| Rate for Payer: Health Management Network Commercial |
$1.78
|
| Rate for Payer: Humana Medicare |
$1.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.89
|
| Rate for Payer: MDX Hawaii PPO |
$2.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.89
|
| Rate for Payer: University Health Alliance Commercial |
$1.53
|
|
|
ISOSORBIDE MONONITRATE 30 MG PO TAB SR 24H
|
Facility
|
IP
|
$2.10
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.04 |
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Health Management Network Commercial |
$1.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: MDX Hawaii PPO |
$2.04
|
|
|
ISOSORBIDE MONONITRATE 60 MG PO TAB SR 24H
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.94 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Health Management Network Commercial |
$1.94
|
| Rate for Payer: Health Management Network Commercial |
$2.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$2.67
|
| Rate for Payer: MDX Hawaii PPO |
$2.21
|
|
|
ISOSORBIDE MONONITRATE 60 MG PO TAB SR 24H
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: AlohaCare Medicaid |
$1.38
|
| Rate for Payer: AlohaCare Medicaid |
$1.14
|
| Rate for Payer: AlohaCare Medicare |
$2.05
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$1.48
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Devoted Health Medicare |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.61
|
| Rate for Payer: Health Management Network Commercial |
$2.34
|
| Rate for Payer: Health Management Network Commercial |
$1.94
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Humana Medicare |
$2.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$2.21
|
| Rate for Payer: MDX Hawaii PPO |
$2.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.05
|
| Rate for Payer: University Health Alliance Commercial |
$2.00
|
| Rate for Payer: University Health Alliance Commercial |
$1.66
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYR
|
Facility
|
OP
|
$55.11
|
|
|
Service Code
|
NDC 70092912043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.55 |
| Max. Negotiated Rate |
$54.56 |
| Rate for Payer: AlohaCare Medicaid |
$27.55
|
| Rate for Payer: AlohaCare Medicare |
$49.60
|
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Devoted Health Medicare |
$54.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.35
|
| Rate for Payer: Health Management Network Commercial |
$46.84
|
| Rate for Payer: Humana Medicare |
$49.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.60
|
| Rate for Payer: MDX Hawaii PPO |
$53.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.60
|
| Rate for Payer: University Health Alliance Commercial |
$40.17
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYR
|
Facility
|
OP
|
$27.60
|
|
|
Service Code
|
NDC 63037013725
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.80 |
| Max. Negotiated Rate |
$27.32 |
| Rate for Payer: AlohaCare Medicaid |
$13.80
|
| Rate for Payer: AlohaCare Medicare |
$24.84
|
| Rate for Payer: Cash Price |
$17.94
|
| Rate for Payer: Devoted Health Medicare |
$27.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.22
|
| Rate for Payer: Health Management Network Commercial |
$23.46
|
| Rate for Payer: Humana Medicare |
$24.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.84
|
| Rate for Payer: MDX Hawaii PPO |
$26.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.84
|
| Rate for Payer: University Health Alliance Commercial |
$20.12
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYR
|
Facility
|
IP
|
$27.60
|
|
|
Service Code
|
NDC 63037013725
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$26.77 |
| Rate for Payer: Cash Price |
$17.94
|
| Rate for Payer: Health Management Network Commercial |
$23.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.84
|
| Rate for Payer: MDX Hawaii PPO |
$26.77
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYR
|
Facility
|
OP
|
$46.55
|
|
|
Service Code
|
NDC 70092112043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$46.08 |
| Rate for Payer: AlohaCare Medicaid |
$23.27
|
| Rate for Payer: AlohaCare Medicare |
$41.90
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Devoted Health Medicare |
$46.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.22
|
| Rate for Payer: Health Management Network Commercial |
$39.57
|
| Rate for Payer: Humana Medicare |
$41.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.90
|
| Rate for Payer: MDX Hawaii PPO |
$45.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.90
|
| Rate for Payer: University Health Alliance Commercial |
$33.93
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYR
|
Facility
|
IP
|
$46.55
|
|
|
Service Code
|
NDC 70092112043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.57 |
| Max. Negotiated Rate |
$45.15 |
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Health Management Network Commercial |
$39.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.90
|
| Rate for Payer: MDX Hawaii PPO |
$45.15
|
|
|
KETAMINE 50 MG/ML (1 ML) IV SYR
|
Facility
|
IP
|
$55.11
|
|
|
Service Code
|
NDC 70092912043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.84 |
| Max. Negotiated Rate |
$53.46 |
| Rate for Payer: Cash Price |
$35.82
|
| Rate for Payer: Health Management Network Commercial |
$46.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.60
|
| Rate for Payer: MDX Hawaii PPO |
$53.46
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$40.56
|
|
|
Service Code
|
NDC 00143950810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.48 |
| Max. Negotiated Rate |
$39.34 |
| Rate for Payer: Cash Price |
$26.36
|
| Rate for Payer: Health Management Network Commercial |
$34.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.50
|
| Rate for Payer: MDX Hawaii PPO |
$39.34
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$40.56
|
|
|
Service Code
|
NDC 00143950810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.28 |
| Max. Negotiated Rate |
$40.15 |
| Rate for Payer: AlohaCare Medicaid |
$20.28
|
| Rate for Payer: AlohaCare Medicare |
$36.50
|
| Rate for Payer: Cash Price |
$26.36
|
| Rate for Payer: Devoted Health Medicare |
$40.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.53
|
| Rate for Payer: Health Management Network Commercial |
$34.48
|
| Rate for Payer: Humana Medicare |
$36.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.50
|
| Rate for Payer: MDX Hawaii PPO |
$39.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.50
|
| Rate for Payer: University Health Alliance Commercial |
$29.56
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
|
OP
|
$40.56
|
|
|
Service Code
|
NDC 00143950801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.28 |
| Max. Negotiated Rate |
$40.15 |
| Rate for Payer: AlohaCare Medicaid |
$20.28
|
| Rate for Payer: AlohaCare Medicare |
$36.50
|
| Rate for Payer: Cash Price |
$26.36
|
| Rate for Payer: Devoted Health Medicare |
$40.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.53
|
| Rate for Payer: Health Management Network Commercial |
$34.48
|
| Rate for Payer: Humana Medicare |
$36.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.50
|
| Rate for Payer: MDX Hawaii PPO |
$39.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.50
|
| Rate for Payer: University Health Alliance Commercial |
$29.56
|
|
|
KETAMINE 50 MG/ML INJ SOLN
|
Facility
|
IP
|
$40.56
|
|
|
Service Code
|
NDC 00143950801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.48 |
| Max. Negotiated Rate |
$39.34 |
| Rate for Payer: Cash Price |
$26.36
|
| Rate for Payer: Health Management Network Commercial |
$34.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.50
|
| Rate for Payer: MDX Hawaii PPO |
$39.34
|
|
|
KETOCONAZOLE 2 % TOP CR
|
Facility
|
IP
|
$512.64
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$435.74 |
| Max. Negotiated Rate |
$497.26 |
| Rate for Payer: Cash Price |
$333.22
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Health Management Network Commercial |
$237.75
|
| Rate for Payer: Health Management Network Commercial |
$435.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$251.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$461.38
|
| Rate for Payer: MDX Hawaii PPO |
$497.26
|
| Rate for Payer: MDX Hawaii PPO |
$271.31
|
|
|
KETOCONAZOLE 2 % TOP CR
|
Facility
|
OP
|
$512.64
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$256.32 |
| Max. Negotiated Rate |
$507.51 |
| Rate for Payer: AlohaCare Medicaid |
$256.32
|
| Rate for Payer: AlohaCare Medicaid |
$139.85
|
| Rate for Payer: AlohaCare Medicare |
$251.73
|
| Rate for Payer: AlohaCare Medicare |
$461.38
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Cash Price |
$333.22
|
| Rate for Payer: Devoted Health Medicare |
$276.90
|
| Rate for Payer: Devoted Health Medicare |
$507.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$461.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$251.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$487.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$265.71
|
| Rate for Payer: Health Management Network Commercial |
$237.75
|
| Rate for Payer: Health Management Network Commercial |
$435.74
|
| Rate for Payer: Humana Medicare |
$251.73
|
| Rate for Payer: Humana Medicare |
$461.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$251.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$461.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$142.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$261.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$461.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$251.73
|
| Rate for Payer: MDX Hawaii PPO |
$497.26
|
| Rate for Payer: MDX Hawaii PPO |
$271.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$251.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$461.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$251.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$461.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$251.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$461.38
|
| Rate for Payer: University Health Alliance Commercial |
$203.87
|
| Rate for Payer: University Health Alliance Commercial |
$373.66
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
|
OP
|
$459.02
|
|
|
Service Code
|
NDC 61314012605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$229.51 |
| Max. Negotiated Rate |
$454.43 |
| Rate for Payer: AlohaCare Medicaid |
$229.51
|
| Rate for Payer: AlohaCare Medicare |
$413.12
|
| Rate for Payer: Cash Price |
$298.36
|
| Rate for Payer: Devoted Health Medicare |
$454.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$413.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$436.07
|
| Rate for Payer: Health Management Network Commercial |
$390.17
|
| Rate for Payer: Humana Medicare |
$413.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$413.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$234.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$413.12
|
| Rate for Payer: MDX Hawaii PPO |
$445.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$413.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$413.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$275.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$413.12
|
| Rate for Payer: University Health Alliance Commercial |
$334.58
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
|
IP
|
$459.02
|
|
|
Service Code
|
NDC 61314012605
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$390.17 |
| Max. Negotiated Rate |
$445.25 |
| Rate for Payer: Cash Price |
$298.36
|
| Rate for Payer: Health Management Network Commercial |
$390.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$413.12
|
| Rate for Payer: MDX Hawaii PPO |
$445.25
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
|
OP
|
$461.87
|
|
|
Service Code
|
NDC 60505100301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.94 |
| Max. Negotiated Rate |
$457.25 |
| Rate for Payer: AlohaCare Medicaid |
$230.94
|
| Rate for Payer: AlohaCare Medicare |
$415.68
|
| Rate for Payer: Cash Price |
$300.22
|
| Rate for Payer: Devoted Health Medicare |
$457.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$415.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$438.78
|
| Rate for Payer: Health Management Network Commercial |
$392.59
|
| Rate for Payer: Humana Medicare |
$415.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$415.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$235.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$415.68
|
| Rate for Payer: MDX Hawaii PPO |
$448.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$415.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$415.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$277.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$415.68
|
| Rate for Payer: University Health Alliance Commercial |
$336.66
|
|
|
KETOROLAC 0.5 % OPHT DROP
|
Facility
|
IP
|
$461.87
|
|
|
Service Code
|
NDC 60505100301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$392.59 |
| Max. Negotiated Rate |
$448.01 |
| Rate for Payer: Cash Price |
$300.22
|
| Rate for Payer: Health Management Network Commercial |
$392.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$415.68
|
| Rate for Payer: MDX Hawaii PPO |
$448.01
|
|
|
KETOROLAC 10 MG PO TABLET
|
Facility
|
IP
|
$11.91
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Health Management Network Commercial |
$10.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.55
|
|
|
KETOROLAC 10 MG PO TABLET
|
Facility
|
OP
|
$11.91
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.96 |
| Max. Negotiated Rate |
$11.79 |
| Rate for Payer: AlohaCare Medicaid |
$5.96
|
| Rate for Payer: AlohaCare Medicare |
$10.72
|
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Devoted Health Medicare |
$11.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.31
|
| Rate for Payer: Health Management Network Commercial |
$10.12
|
| Rate for Payer: Humana Medicare |
$10.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.68
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJ SOLN
|
Facility
|
IP
|
$27.55
|
|
|
Service Code
|
HCPCS J1885
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.42 |
| Max. Negotiated Rate |
$26.72 |
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Health Management Network Commercial |
$23.42
|
| Rate for Payer: Health Management Network Commercial |
$8.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.69
|
| Rate for Payer: MDX Hawaii PPO |
$9.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.72
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJ SOLN
|
Facility
|
OP
|
$9.66
|
|
|
Service Code
|
HCPCS J1885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$9.56 |
| Rate for Payer: AlohaCare Medicaid |
$4.83
|
| Rate for Payer: AlohaCare Medicaid |
$13.78
|
| Rate for Payer: AlohaCare Medicare |
$8.69
|
| Rate for Payer: AlohaCare Medicare |
$24.80
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cash Price |
$17.91
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Devoted Health Medicare |
$27.27
|
| Rate for Payer: Devoted Health Medicare |
$9.56
|
| 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 Medicare |
$24.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.69
|
| 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 |
$26.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.18
|
| Rate for Payer: Health Management Network Commercial |
$23.42
|
| Rate for Payer: Health Management Network Commercial |
$8.21
|
| Rate for Payer: Humana Medicare |
$24.80
|
| Rate for Payer: Humana Medicare |
$8.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.69
|
| Rate for Payer: MDX Hawaii PPO |
$9.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.80
|
| Rate for Payer: University Health Alliance Commercial |
$20.08
|
| Rate for Payer: University Health Alliance Commercial |
$7.04
|
|
