|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
OP
|
$44.22
|
|
|
Service Code
|
NDC 00409420810
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.11 |
| Max. Negotiated Rate |
$42.89 |
| Rate for Payer: AlohaCare Medicaid |
$22.11
|
| Rate for Payer: AlohaCare Medicare |
$22.11
|
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Devoted Health Medicare |
$24.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.01
|
| Rate for Payer: Health Management Network Commercial |
$37.59
|
| Rate for Payer: Humana Medicare |
$22.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.11
|
| Rate for Payer: MDX Hawaii PPO |
$42.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.11
|
| Rate for Payer: University Health Alliance Commercial |
$32.23
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
IP
|
$44.22
|
|
|
Service Code
|
NDC 00409420810
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.59 |
| Max. Negotiated Rate |
$42.89 |
| Rate for Payer: Cash Price |
$28.74
|
| Rate for Payer: Health Management Network Commercial |
$37.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.80
|
| Rate for Payer: MDX Hawaii PPO |
$42.89
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
OP
|
$16.96
|
|
|
Service Code
|
NDC 00409904517
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$16.45 |
| Rate for Payer: AlohaCare Medicaid |
$8.48
|
| Rate for Payer: AlohaCare Medicare |
$8.48
|
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Devoted Health Medicare |
$9.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.11
|
| Rate for Payer: Health Management Network Commercial |
$14.42
|
| Rate for Payer: Humana Medicare |
$8.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.48
|
| Rate for Payer: MDX Hawaii PPO |
$16.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.48
|
| Rate for Payer: University Health Alliance Commercial |
$12.36
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
IP
|
$32.88
|
|
|
Service Code
|
NDC 00409174929
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.95 |
| Max. Negotiated Rate |
$31.89 |
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Health Management Network Commercial |
$27.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.59
|
| Rate for Payer: MDX Hawaii PPO |
$31.89
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
IP
|
$16.96
|
|
|
Service Code
|
NDC 00409904517
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$16.45 |
| Rate for Payer: Cash Price |
$11.02
|
| Rate for Payer: Health Management Network Commercial |
$14.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.26
|
| Rate for Payer: MDX Hawaii PPO |
$16.45
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
OP
|
$58.14
|
|
|
Service Code
|
NDC 63323046237
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.07 |
| Max. Negotiated Rate |
$56.40 |
| Rate for Payer: AlohaCare Medicaid |
$29.07
|
| Rate for Payer: AlohaCare Medicare |
$29.07
|
| Rate for Payer: Cash Price |
$37.79
|
| Rate for Payer: Devoted Health Medicare |
$31.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.23
|
| Rate for Payer: Health Management Network Commercial |
$49.42
|
| Rate for Payer: Humana Medicare |
$29.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.07
|
| Rate for Payer: MDX Hawaii PPO |
$56.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.07
|
| Rate for Payer: University Health Alliance Commercial |
$42.38
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
IP
|
$58.14
|
|
|
Service Code
|
NDC 63323046237
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.42 |
| Max. Negotiated Rate |
$56.40 |
| Rate for Payer: Cash Price |
$37.79
|
| Rate for Payer: Health Management Network Commercial |
$49.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.33
|
| Rate for Payer: MDX Hawaii PPO |
$56.40
|
|
|
bupivac-0.5%-EPI 1:200,000 (PF) vial 30 ml [HHSC]
|
Facility
|
OP
|
$32.88
|
|
|
Service Code
|
NDC 00409174929
|
| Hospital Charge Code |
2500126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.44 |
| Max. Negotiated Rate |
$31.89 |
| Rate for Payer: AlohaCare Medicaid |
$16.44
|
| Rate for Payer: AlohaCare Medicare |
$16.44
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Devoted Health Medicare |
$18.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.24
|
| Rate for Payer: Health Management Network Commercial |
$27.95
|
| Rate for Payer: Humana Medicare |
$16.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.44
|
| Rate for Payer: MDX Hawaii PPO |
$31.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.44
|
| Rate for Payer: University Health Alliance Commercial |
$23.97
|
|
|
bupivacaine 0.25% (PF) vial 30 ml [HHSC]
|
Facility
|
IP
|
$13.27
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
2500120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.28 |
| Max. Negotiated Rate |
$12.87 |
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Cash Price |
$7.51
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Health Management Network Commercial |
$9.83
|
| Rate for Payer: Health Management Network Commercial |
$11.28
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$8.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.94
|
| Rate for Payer: MDX Hawaii PPO |
$11.21
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$9.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.87
|
|
|
bupivacaine 0.25% (PF) vial 30 ml [HHSC]
|
Facility
|
OP
|
$44.74
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
2500120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicaid |
$4.96
|
| Rate for Payer: AlohaCare Medicaid |
$6.63
|
| Rate for Payer: AlohaCare Medicaid |
$5.78
|
| Rate for Payer: AlohaCare Medicare |
$5.78
|
| Rate for Payer: AlohaCare Medicare |
$6.63
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$7.51
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Cash Price |
$8.63
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Cash Price |
$7.51
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Devoted Health Medicare |
$7.30
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$6.36
|
| Rate for Payer: Devoted Health Medicare |
$5.46
|
| 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 ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| 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 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 |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.43
|
| Rate for Payer: Health Management Network Commercial |
$8.44
|
| Rate for Payer: Health Management Network Commercial |
$11.28
|
| Rate for Payer: Health Management Network Commercial |
$9.83
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Humana Medicare |
$6.63
|
| Rate for Payer: Humana Medicare |
$5.78
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.78
|
| Rate for Payer: MDX Hawaii PPO |
$9.63
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$12.87
|
| Rate for Payer: MDX Hawaii PPO |
$11.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.78
|
| Rate for Payer: University Health Alliance Commercial |
$7.24
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$8.43
|
| Rate for Payer: University Health Alliance Commercial |
$9.67
|
|
|
bupivacaine 0.5% (PF) vial 30 ml [HHSC]
|
Facility
|
OP
|
$12.14
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
2500122
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$11.78 |
| Rate for Payer: AlohaCare Medicaid |
$6.07
|
| Rate for Payer: AlohaCare Medicaid |
$26.02
|
| Rate for Payer: AlohaCare Medicaid |
$9.84
|
| Rate for Payer: AlohaCare Medicare |
$9.84
|
| Rate for Payer: AlohaCare Medicare |
$6.07
|
| Rate for Payer: AlohaCare Medicare |
$26.02
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Devoted Health Medicare |
$6.68
|
| Rate for Payer: Devoted Health Medicare |
$28.63
|
| Rate for Payer: Devoted Health Medicare |
$10.82
|
| 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 ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.84
|
| 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 Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.45
|
| Rate for Payer: Health Management Network Commercial |
$44.24
|
| Rate for Payer: Health Management Network Commercial |
$10.32
|
| Rate for Payer: Health Management Network Commercial |
$16.73
|
| Rate for Payer: Humana Medicare |
$6.07
|
| Rate for Payer: Humana Medicare |
$9.84
|
| Rate for Payer: Humana Medicare |
$26.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.02
|
| Rate for Payer: MDX Hawaii PPO |
$50.49
|
| Rate for Payer: MDX Hawaii PPO |
$19.09
|
| Rate for Payer: MDX Hawaii PPO |
$11.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.02
|
| Rate for Payer: University Health Alliance Commercial |
$8.85
|
| Rate for Payer: University Health Alliance Commercial |
$14.34
|
| Rate for Payer: University Health Alliance Commercial |
$37.94
|
|
|
bupivacaine 0.5% (PF) vial 30 ml [HHSC]
|
Facility
|
IP
|
$52.05
|
|
|
Service Code
|
HCPCS J0665
|
| Hospital Charge Code |
2500122
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.24 |
| Max. Negotiated Rate |
$50.49 |
| Rate for Payer: Cash Price |
$33.83
|
| Rate for Payer: Cash Price |
$12.79
|
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Health Management Network Commercial |
$10.32
|
| Rate for Payer: Health Management Network Commercial |
$44.24
|
| Rate for Payer: Health Management Network Commercial |
$16.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.93
|
| Rate for Payer: MDX Hawaii PPO |
$19.09
|
| Rate for Payer: MDX Hawaii PPO |
$11.78
|
| Rate for Payer: MDX Hawaii PPO |
$50.49
|
|
|
buprenorphine SL 8 mg tablet [HHSC]
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
2500127
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.68 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: AlohaCare Medicaid |
$11.68
|
| Rate for Payer: AlohaCare Medicaid |
$25.44
|
| Rate for Payer: AlohaCare Medicaid |
$8.06
|
| Rate for Payer: AlohaCare Medicaid |
$25.10
|
| Rate for Payer: AlohaCare Medicare |
$11.68
|
| Rate for Payer: AlohaCare Medicare |
$25.10
|
| Rate for Payer: AlohaCare Medicare |
$25.44
|
| Rate for Payer: AlohaCare Medicare |
$8.06
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cash Price |
$10.48
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Devoted Health Medicare |
$27.98
|
| Rate for Payer: Devoted Health Medicare |
$27.61
|
| Rate for Payer: Devoted Health Medicare |
$8.87
|
| Rate for Payer: Devoted Health Medicare |
$12.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.34
|
| Rate for Payer: Health Management Network Commercial |
$13.70
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Health Management Network Commercial |
$43.25
|
| Rate for Payer: Health Management Network Commercial |
$42.67
|
| Rate for Payer: Humana Medicare |
$25.44
|
| Rate for Payer: Humana Medicare |
$25.10
|
| Rate for Payer: Humana Medicare |
$8.06
|
| Rate for Payer: Humana Medicare |
$11.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.06
|
| Rate for Payer: MDX Hawaii PPO |
$15.64
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$49.35
|
| Rate for Payer: MDX Hawaii PPO |
$48.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.44
|
| Rate for Payer: University Health Alliance Commercial |
$11.75
|
| Rate for Payer: University Health Alliance Commercial |
$17.02
|
| Rate for Payer: University Health Alliance Commercial |
$36.59
|
| Rate for Payer: University Health Alliance Commercial |
$37.09
|
|
|
buprenorphine SL 8 mg tablet [HHSC]
|
Facility
|
IP
|
$23.35
|
|
|
Service Code
|
HCPCS J0571
|
| Hospital Charge Code |
2500127
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$33.07
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cash Price |
$10.48
|
| Rate for Payer: Health Management Network Commercial |
$42.67
|
| Rate for Payer: Health Management Network Commercial |
$13.70
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Health Management Network Commercial |
$43.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.79
|
| Rate for Payer: MDX Hawaii PPO |
$49.35
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$15.64
|
| Rate for Payer: MDX Hawaii PPO |
$48.69
|
|
|
buPROPion ER 150 mg tablet [HHSC]
|
Facility
|
IP
|
$29.02
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.67 |
| Max. Negotiated Rate |
$28.15 |
| Rate for Payer: Cash Price |
$18.86
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Cash Price |
$16.84
|
| Rate for Payer: Health Management Network Commercial |
$24.67
|
| Rate for Payer: Health Management Network Commercial |
$22.02
|
| Rate for Payer: Health Management Network Commercial |
$22.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.12
|
| Rate for Payer: MDX Hawaii PPO |
$25.74
|
| Rate for Payer: MDX Hawaii PPO |
$25.12
|
| Rate for Payer: MDX Hawaii PPO |
$28.15
|
|
|
buPROPion ER 150 mg tablet [HHSC]
|
Facility
|
OP
|
$29.02
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2500128
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.51 |
| Max. Negotiated Rate |
$28.15 |
| Rate for Payer: AlohaCare Medicaid |
$14.51
|
| Rate for Payer: AlohaCare Medicaid |
$12.95
|
| Rate for Payer: AlohaCare Medicaid |
$13.27
|
| Rate for Payer: AlohaCare Medicare |
$12.95
|
| Rate for Payer: AlohaCare Medicare |
$14.51
|
| Rate for Payer: AlohaCare Medicare |
$13.27
|
| Rate for Payer: Cash Price |
$17.25
|
| Rate for Payer: Cash Price |
$16.84
|
| Rate for Payer: Cash Price |
$18.86
|
| Rate for Payer: Devoted Health Medicare |
$14.60
|
| Rate for Payer: Devoted Health Medicare |
$14.24
|
| Rate for Payer: Devoted Health Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.61
|
| Rate for Payer: Health Management Network Commercial |
$22.02
|
| Rate for Payer: Health Management Network Commercial |
$24.67
|
| Rate for Payer: Health Management Network Commercial |
$22.56
|
| Rate for Payer: Humana Medicare |
$12.95
|
| Rate for Payer: Humana Medicare |
$13.27
|
| Rate for Payer: Humana Medicare |
$14.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.27
|
| Rate for Payer: MDX Hawaii PPO |
$28.15
|
| Rate for Payer: MDX Hawaii PPO |
$25.74
|
| Rate for Payer: MDX Hawaii PPO |
$25.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.95
|
| Rate for Payer: University Health Alliance Commercial |
$16.25
|
| Rate for Payer: University Health Alliance Commercial |
$14.50
|
| Rate for Payer: University Health Alliance Commercial |
$14.86
|
|
|
busPIRone 15 mg tablet [HHSC]
|
Facility
|
OP
|
$11.23
|
|
|
Service Code
|
NDC 29300024601
|
| Hospital Charge Code |
2500131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: AlohaCare Medicaid |
$5.62
|
| Rate for Payer: AlohaCare Medicare |
$5.62
|
| Rate for Payer: Cash Price |
$7.30
|
| Rate for Payer: Devoted Health Medicare |
$6.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.67
|
| Rate for Payer: Health Management Network Commercial |
$9.55
|
| Rate for Payer: Humana Medicare |
$5.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.62
|
| Rate for Payer: MDX Hawaii PPO |
$10.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.62
|
| Rate for Payer: University Health Alliance Commercial |
$8.19
|
|
|
busPIRone 15 mg tablet [HHSC]
|
Facility
|
OP
|
$11.76
|
|
|
Service Code
|
NDC 64380074303
|
| Hospital Charge Code |
2500131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$11.41 |
| Rate for Payer: AlohaCare Medicaid |
$5.88
|
| Rate for Payer: AlohaCare Medicare |
$5.88
|
| Rate for Payer: Cash Price |
$7.64
|
| Rate for Payer: Devoted Health Medicare |
$6.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.17
|
| Rate for Payer: Health Management Network Commercial |
$10.00
|
| Rate for Payer: Humana Medicare |
$5.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.88
|
| Rate for Payer: MDX Hawaii PPO |
$11.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.88
|
| Rate for Payer: University Health Alliance Commercial |
$8.57
|
|
|
busPIRone 15 mg tablet [HHSC]
|
Facility
|
OP
|
$11.23
|
|
|
Service Code
|
NDC 68382018201
|
| Hospital Charge Code |
2500131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.62 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: AlohaCare Medicaid |
$5.62
|
| Rate for Payer: AlohaCare Medicare |
$5.62
|
| Rate for Payer: Cash Price |
$7.30
|
| Rate for Payer: Devoted Health Medicare |
$6.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.67
|
| Rate for Payer: Health Management Network Commercial |
$9.55
|
| Rate for Payer: Humana Medicare |
$5.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.62
|
| Rate for Payer: MDX Hawaii PPO |
$10.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.62
|
| Rate for Payer: University Health Alliance Commercial |
$8.19
|
|
|
busPIRone 15 mg tablet [HHSC]
|
Facility
|
IP
|
$11.76
|
|
|
Service Code
|
NDC 64380074303
|
| Hospital Charge Code |
2500131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$11.41 |
| Rate for Payer: Cash Price |
$7.64
|
| Rate for Payer: Health Management Network Commercial |
$10.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.58
|
| Rate for Payer: MDX Hawaii PPO |
$11.41
|
|
|
busPIRone 15 mg tablet [HHSC]
|
Facility
|
IP
|
$11.23
|
|
|
Service Code
|
NDC 68382018201
|
| Hospital Charge Code |
2500131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: Cash Price |
$7.30
|
| Rate for Payer: Health Management Network Commercial |
$9.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.11
|
| Rate for Payer: MDX Hawaii PPO |
$10.89
|
|
|
busPIRone 15 mg tablet [HHSC]
|
Facility
|
IP
|
$11.23
|
|
|
Service Code
|
NDC 29300024601
|
| Hospital Charge Code |
2500131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.55 |
| Max. Negotiated Rate |
$10.89 |
| Rate for Payer: Cash Price |
$7.30
|
| Rate for Payer: Health Management Network Commercial |
$9.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.11
|
| Rate for Payer: MDX Hawaii PPO |
$10.89
|
|
|
C8921 TTE w or wo Fol w Contr Compl Charge
|
Facility
|
IP
|
$2,589.00
|
|
|
Service Code
|
HCPCS C8921
|
| Hospital Charge Code |
8220672
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$2,200.65 |
| Max. Negotiated Rate |
$2,511.33 |
| Rate for Payer: Cash Price |
$1,682.85
|
| Rate for Payer: Health Management Network Commercial |
$2,200.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,330.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,511.33
|
|
|
C8921 TTE w or wo Fol w Contr Compl Charge
|
Facility
|
OP
|
$2,589.00
|
|
|
Service Code
|
HCPCS C8921
|
| Hospital Charge Code |
8220672
|
|
Hospital Revenue Code
|
483
|
| Min. Negotiated Rate |
$592.55 |
| Max. Negotiated Rate |
$2,511.33 |
| Rate for Payer: AlohaCare Medicaid |
$1,294.50
|
| Rate for Payer: AlohaCare Medicare |
$1,294.50
|
| Rate for Payer: Cash Price |
$1,682.85
|
| Rate for Payer: Cash Price |
$1,682.85
|
| Rate for Payer: Devoted Health Medicare |
$1,423.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,001.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,294.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,459.55
|
| Rate for Payer: Health Management Network Commercial |
$2,200.65
|
| Rate for Payer: Humana Medicare |
$1,294.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,330.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,320.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,294.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,511.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,294.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,294.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$592.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,294.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,449.84
|
|
|
C8957 Prolonged IV Inf Req Pump Charge
|
Facility
|
IP
|
$588.00
|
|
|
Service Code
|
HCPCS C8957
|
| Hospital Charge Code |
8220036
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$499.80 |
| Max. Negotiated Rate |
$570.36 |
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Health Management Network Commercial |
$499.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$529.20
|
| Rate for Payer: MDX Hawaii PPO |
$570.36
|
|
