|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68084034211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68084034201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
TOPIRAMATE 25 MG TABLET [18920]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084034201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS J9351
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$467.40
|
| Rate for Payer: Health Management Network Commercial |
$353.60
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: MDX Hawaii PPO |
$403.52
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS J9351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$467.40
|
| Rate for Payer: Cash Price |
$249.60
|
| Rate for Payer: Cash Price |
$467.40
|
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$395.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$110.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$740.05
|
| Rate for Payer: Health Management Network Commercial |
$662.15
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Health Management Network Commercial |
$353.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$490.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$262.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$59.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$397.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.16
|
| Rate for Payer: MDX Hawaii PPO |
$755.63
|
| Rate for Payer: MDX Hawaii PPO |
$403.52
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$249.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$467.40
|
| Rate for Payer: University Health Alliance Commercial |
$303.22
|
| Rate for Payer: University Health Alliance Commercial |
$84.55
|
| Rate for Payer: University Health Alliance Commercial |
$567.81
|
|
|
TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) INTRAVENOUS SOLUTION [195440]
|
Facility
|
IP
|
$11,928.00
|
|
|
Service Code
|
HCPCS J3263
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,138.80 |
| Max. Negotiated Rate |
$11,570.16 |
| Rate for Payer: Cash Price |
$7,156.80
|
| Rate for Payer: Health Management Network Commercial |
$10,138.80
|
| Rate for Payer: MDX Hawaii PPO |
$11,570.16
|
|
|
TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) INTRAVENOUS SOLUTION [195440]
|
Facility
|
OP
|
$11,928.00
|
|
|
Service Code
|
HCPCS J3263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.50 |
| Max. Negotiated Rate |
$11,570.16 |
| Rate for Payer: AlohaCare Medicaid |
$39.99
|
| Rate for Payer: AlohaCare Medicare |
$39.99
|
| Rate for Payer: Cash Price |
$7,156.80
|
| Rate for Payer: Cash Price |
$7,156.80
|
| Rate for Payer: Devoted Health Medicare |
$43.99
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$39.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$49.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$39.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,331.60
|
| Rate for Payer: Health Management Network Commercial |
$10,138.80
|
| Rate for Payer: Humana Medicare |
$39.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,514.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,083.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.99
|
| Rate for Payer: MDX Hawaii PPO |
$11,570.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,156.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.99
|
| Rate for Payer: University Health Alliance Commercial |
$8,694.32
|
|
|
TORPEDO 4.0MMX7CM AR-7400TD
|
Facility
|
IP
|
$379.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$322.15 |
| Max. Negotiated Rate |
$367.63 |
| Rate for Payer: Cash Price |
$227.40
|
| Rate for Payer: Health Management Network Commercial |
$322.15
|
| Rate for Payer: MDX Hawaii PPO |
$367.63
|
|
|
TORPEDO 4.0MMX7CM AR-7400TD
|
Facility
|
OP
|
$379.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$193.29 |
| Max. Negotiated Rate |
$367.63 |
| Rate for Payer: Cash Price |
$227.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$360.05
|
| Rate for Payer: Health Management Network Commercial |
$322.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$238.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$193.29
|
| Rate for Payer: MDX Hawaii PPO |
$367.63
|
| Rate for Payer: University Health Alliance Commercial |
$276.25
|
|
|
TORPEDO 4MMX13CM AR-8400TD
|
Facility
|
IP
|
$544.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.40 |
| Max. Negotiated Rate |
$527.68 |
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Health Management Network Commercial |
$462.40
|
| Rate for Payer: MDX Hawaii PPO |
$527.68
|
|
|
TORPEDO 4MMX13CM AR-8400TD
|
Facility
|
OP
|
$544.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.44 |
| Max. Negotiated Rate |
$527.68 |
| Rate for Payer: Cash Price |
$326.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$516.80
|
| Rate for Payer: Health Management Network Commercial |
$462.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$277.44
|
| Rate for Payer: MDX Hawaii PPO |
$527.68
|
| Rate for Payer: University Health Alliance Commercial |
$396.52
|
|
|
TORQUE-OLCOTT TORQUE DEVICE (O
|
Facility
|
IP
|
$96.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
|
|
TORQUE-OLCOTT TORQUE DEVICE (O
|
Facility
|
OP
|
$96.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.96 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.20
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.96
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
| Rate for Payer: University Health Alliance Commercial |
$69.97
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084053901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268075615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084053911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084053911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268075615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
TORSEMIDE 20 MG TABLET [18293]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084053901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
TOTAL HIP FEMORAL STEM 52-3418
|
Facility
|
IP
|
$8,873.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,968.88 |
| Max. Negotiated Rate |
$8,606.81 |
| Rate for Payer: Cash Price |
$5,323.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,211.10
|
| Rate for Payer: Health Management Network Commercial |
$7,542.05
|
| Rate for Payer: MDX Hawaii PPO |
$8,606.81
|
| Rate for Payer: University Health Alliance Commercial |
$4,968.88
|
|
|
TOTAL HIP FEMORAL STEM 52-3418
|
Facility
|
OP
|
$8,873.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,525.23 |
| Max. Negotiated Rate |
$8,606.81 |
| Rate for Payer: Cash Price |
$5,323.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,211.10
|
| Rate for Payer: Health Management Network Commercial |
$7,542.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,589.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,525.23
|
| Rate for Payer: MDX Hawaii PPO |
$8,606.81
|
| Rate for Payer: University Health Alliance Commercial |
$4,968.88
|
|
|
TOTAL HIP PROXIMAL 18D 55-0524
|
Facility
|
IP
|
$4,310.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,413.60 |
| Max. Negotiated Rate |
$4,180.70 |
| Rate for Payer: Cash Price |
$2,586.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,017.00
|
| Rate for Payer: Health Management Network Commercial |
$3,663.50
|
| Rate for Payer: MDX Hawaii PPO |
$4,180.70
|
| Rate for Payer: University Health Alliance Commercial |
$2,413.60
|
|
|
TOTAL HIP PROXIMAL 18D 55-0524
|
Facility
|
OP
|
$4,310.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,198.10 |
| Max. Negotiated Rate |
$4,180.70 |
| Rate for Payer: Cash Price |
$2,586.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,017.00
|
| Rate for Payer: Health Management Network Commercial |
$3,663.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,715.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,198.10
|
| Rate for Payer: MDX Hawaii PPO |
$4,180.70
|
| Rate for Payer: University Health Alliance Commercial |
$2,413.60
|
|
|
TOTAL STABILIZER FEM 5512-F-40
|
Facility
|
OP
|
$12,283.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,264.33 |
| Max. Negotiated Rate |
$11,914.51 |
| Rate for Payer: Cash Price |
$7,369.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,598.10
|
| Rate for Payer: Health Management Network Commercial |
$10,440.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,738.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,264.33
|
| Rate for Payer: MDX Hawaii PPO |
$11,914.51
|
| Rate for Payer: University Health Alliance Commercial |
$6,878.48
|
|
|
TOTAL STABILIZER FEM 5512-F-40
|
Facility
|
IP
|
$12,283.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,878.48 |
| Max. Negotiated Rate |
$11,914.51 |
| Rate for Payer: Cash Price |
$7,369.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,598.10
|
| Rate for Payer: Health Management Network Commercial |
$10,440.55
|
| Rate for Payer: MDX Hawaii PPO |
$11,914.51
|
| Rate for Payer: University Health Alliance Commercial |
$6,878.48
|
|
