|
TREMELIMUMAB-ACTL 20 MG/ML INTRAVENOUS SOLUTION [188830]
|
Facility
|
IP
|
$50,165.00
|
|
|
Service Code
|
HCPCS J9347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42,640.25 |
| Max. Negotiated Rate |
$48,660.05 |
| Rate for Payer: Cash Price |
$30,099.00
|
| Rate for Payer: Cash Price |
$7,750.20
|
| Rate for Payer: Cash Price |
$4,571.40
|
| Rate for Payer: Health Management Network Commercial |
$10,979.45
|
| Rate for Payer: Health Management Network Commercial |
$42,640.25
|
| Rate for Payer: Health Management Network Commercial |
$6,476.15
|
| Rate for Payer: MDX Hawaii PPO |
$7,390.43
|
| Rate for Payer: MDX Hawaii PPO |
$48,660.05
|
| Rate for Payer: MDX Hawaii PPO |
$12,529.49
|
|
|
TRIALTHON INSERT 5531-G-709-E
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
TRIALTHON INSERT 5531-G-709-E
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,364.76 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,685.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,364.76
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
TRIALYSIS CATH TRAY 13FR 20CM
|
Facility
|
OP
|
$724.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$369.24 |
| Max. Negotiated Rate |
$702.28 |
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$687.80
|
| Rate for Payer: Health Management Network Commercial |
$615.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$456.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$369.24
|
| Rate for Payer: MDX Hawaii PPO |
$702.28
|
| Rate for Payer: University Health Alliance Commercial |
$527.72
|
|
|
TRIALYSIS CATH TRAY 13FR 20CM
|
Facility
|
IP
|
$724.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$615.40 |
| Max. Negotiated Rate |
$702.28 |
| Rate for Payer: Cash Price |
$434.40
|
| Rate for Payer: Health Management Network Commercial |
$615.40
|
| Rate for Payer: MDX Hawaii PPO |
$702.28
|
|
|
TRIAMCINOLONE 0.1% CREAM (KENALOG) (15 GRAM) (TAKE HOME) [4080399]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080188
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
TRIAMCINOLONE 0.1% CREAM (KENALOG) (15 GRAM) (TAKE HOME) [4080399]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080188
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
NDC 51672126705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.02 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.90
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.02
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
| Rate for Payer: University Health Alliance Commercial |
$147.24
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
NDC 64980032005
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.02 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.90
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$103.02
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
| Rate for Payer: University Health Alliance Commercial |
$147.24
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
NDC 51672126705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
NDC 64980032005
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
NDC 00713067653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$299.25
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$160.65
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
| Rate for Payer: University Health Alliance Commercial |
$229.60
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
OP
|
$315.00
|
|
|
Service Code
|
NDC 42571038519
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$299.25
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$160.65
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
| Rate for Payer: University Health Alliance Commercial |
$229.60
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
NDC 00713067653
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.75 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % LOTION [8116]
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
NDC 42571038519
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$267.75 |
| Max. Negotiated Rate |
$305.55 |
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Health Management Network Commercial |
$267.75
|
| Rate for Payer: MDX Hawaii PPO |
$305.55
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 00168000415
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 00168000415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 00168000480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 45802006435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
NDC 45802006436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 67877025115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 00168000480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 45802006435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
NDC 45802006436
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.34 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: University Health Alliance Commercial |
$24.78
|
|
|
TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM [8113]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 51672128201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
