|
RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN [139635]
|
Facility
|
OP
|
$13,529.00
|
|
|
Service Code
|
HCPCS J9311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.28 |
| Max. Negotiated Rate |
$13,123.13 |
| Rate for Payer: AlohaCare Medicaid |
$36.28
|
| Rate for Payer: AlohaCare Medicare |
$36.28
|
| Rate for Payer: Cash Price |
$8,117.40
|
| Rate for Payer: Cash Price |
$8,117.40
|
| Rate for Payer: Devoted Health Medicare |
$39.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,852.55
|
| Rate for Payer: Health Management Network Commercial |
$11,499.65
|
| Rate for Payer: Humana Medicare |
$36.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,523.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,899.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.28
|
| Rate for Payer: MDX Hawaii PPO |
$13,123.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,117.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.28
|
| Rate for Payer: University Health Alliance Commercial |
$9,861.29
|
|
|
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION [170115]
|
Facility
|
IP
|
$7,610.00
|
|
|
Service Code
|
HCPCS Q5115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,468.50 |
| Max. Negotiated Rate |
$7,381.70 |
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cash Price |
$913.20
|
| Rate for Payer: Cash Price |
$5,068.80
|
| Rate for Payer: Health Management Network Commercial |
$1,293.70
|
| Rate for Payer: Health Management Network Commercial |
$6,468.50
|
| Rate for Payer: Health Management Network Commercial |
$7,180.80
|
| Rate for Payer: MDX Hawaii PPO |
$8,194.56
|
| Rate for Payer: MDX Hawaii PPO |
$7,381.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,476.34
|
|
|
RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION [170115]
|
Facility
|
OP
|
$7,610.00
|
|
|
Service Code
|
HCPCS Q5115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.18 |
| Max. Negotiated Rate |
$7,381.70 |
| Rate for Payer: AlohaCare Medicaid |
$31.28
|
| Rate for Payer: AlohaCare Medicaid |
$31.28
|
| Rate for Payer: AlohaCare Medicaid |
$31.28
|
| Rate for Payer: AlohaCare Medicare |
$31.28
|
| Rate for Payer: AlohaCare Medicare |
$31.28
|
| Rate for Payer: AlohaCare Medicare |
$31.28
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cash Price |
$913.20
|
| Rate for Payer: Cash Price |
$5,068.80
|
| Rate for Payer: Cash Price |
$5,068.80
|
| Rate for Payer: Cash Price |
$913.20
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Devoted Health Medicare |
$34.41
|
| Rate for Payer: Devoted Health Medicare |
$34.41
|
| Rate for Payer: Devoted Health Medicare |
$34.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$31.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$31.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$31.18
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$31.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$31.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$31.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,025.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,445.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,229.50
|
| Rate for Payer: Health Management Network Commercial |
$6,468.50
|
| Rate for Payer: Health Management Network Commercial |
$7,180.80
|
| Rate for Payer: Health Management Network Commercial |
$1,293.70
|
| Rate for Payer: Humana Medicare |
$31.28
|
| Rate for Payer: Humana Medicare |
$31.28
|
| Rate for Payer: Humana Medicare |
$31.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,794.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$958.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,322.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$776.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,881.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,308.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.28
|
| Rate for Payer: MDX Hawaii PPO |
$7,381.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,476.34
|
| Rate for Payer: MDX Hawaii PPO |
$8,194.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$913.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,566.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,068.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.28
|
| Rate for Payer: University Health Alliance Commercial |
$5,546.93
|
| Rate for Payer: University Health Alliance Commercial |
$6,157.75
|
| Rate for Payer: University Health Alliance Commercial |
$1,109.39
|
|
|
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION [171639]
|
Facility
|
OP
|
$8,602.00
|
|
|
Service Code
|
HCPCS Q5119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.69 |
| Max. Negotiated Rate |
$8,343.94 |
| Rate for Payer: AlohaCare Medicaid |
$13.69
|
| Rate for Payer: AlohaCare Medicaid |
$13.69
|
| Rate for Payer: AlohaCare Medicaid |
$13.69
|
| Rate for Payer: AlohaCare Medicare |
$13.69
|
| Rate for Payer: AlohaCare Medicare |
$13.69
|
| Rate for Payer: AlohaCare Medicare |
$13.69
|
| Rate for Payer: Cash Price |
$5,161.20
|
| Rate for Payer: Cash Price |
$1,032.60
|
| Rate for Payer: Cash Price |
$5,728.80
|
| Rate for Payer: Cash Price |
$5,728.80
|
| Rate for Payer: Cash Price |
$1,032.60
|
| Rate for Payer: Cash Price |
$5,161.20
|
| Rate for Payer: Devoted Health Medicare |
$15.06
|
| Rate for Payer: Devoted Health Medicare |
$15.06
|
| Rate for Payer: Devoted Health Medicare |
$15.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.11
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.11
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$26.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,070.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,634.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,171.90
|
| Rate for Payer: Health Management Network Commercial |
$7,311.70
|
| Rate for Payer: Health Management Network Commercial |
$8,115.80
|
| Rate for Payer: Health Management Network Commercial |
$1,462.85
|
| Rate for Payer: Humana Medicare |
$13.69
|
| Rate for Payer: Humana Medicare |
$13.69
|
| Rate for Payer: Humana Medicare |
$13.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,419.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,084.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,015.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$877.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,387.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,869.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.69
|
| Rate for Payer: MDX Hawaii PPO |
$8,343.94
|
| Rate for Payer: MDX Hawaii PPO |
$1,669.37
|
| Rate for Payer: MDX Hawaii PPO |
$9,261.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,032.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,161.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,728.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.69
|
| Rate for Payer: University Health Alliance Commercial |
$6,270.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,959.54
|
| Rate for Payer: University Health Alliance Commercial |
$1,254.44
|
|
|
RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION [171639]
|
Facility
|
IP
|
$8,602.00
|
|
|
Service Code
|
HCPCS Q5119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,311.70 |
| Max. Negotiated Rate |
$8,343.94 |
| Rate for Payer: Cash Price |
$5,161.20
|
| Rate for Payer: Cash Price |
$1,032.60
|
| Rate for Payer: Cash Price |
$5,728.80
|
| Rate for Payer: Health Management Network Commercial |
$1,462.85
|
| Rate for Payer: Health Management Network Commercial |
$7,311.70
|
| Rate for Payer: Health Management Network Commercial |
$8,115.80
|
| Rate for Payer: MDX Hawaii PPO |
$9,261.56
|
| Rate for Payer: MDX Hawaii PPO |
$8,343.94
|
| Rate for Payer: MDX Hawaii PPO |
$1,669.37
|
|
|
RIVAROXABAN 10 MG TABLET [110250]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458058010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 10 MG TABLET [110250]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458058030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 10 MG TABLET [110250]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458058030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 10 MG TABLET [110250]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458058010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 15 MG TABLET [112834]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458057801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 15 MG TABLET [112834]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458057810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 15 MG TABLET [112834]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458057810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 15 MG TABLET [112834]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458057801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 20 MG TABLET [112835]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458057910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 20 MG TABLET [112835]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458057990
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 20 MG TABLET [112835]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458057910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 20 MG TABLET [112835]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50458057901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
RIVAROXABAN 20 MG TABLET [112835]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458057990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 20 MG TABLET [112835]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50458057901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
RIVAROXABAN 2.5 MG TABLET [164486]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 50458057710
|
|
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
|
|
|
RIVAROXABAN 2.5 MG TABLET [164486]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 50458057760
|
|
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
|
|
|
RIVAROXABAN 2.5 MG TABLET [164486]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 50458057760
|
|
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
|
|
|
RIVAROXABAN 2.5 MG TABLET [164486]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 50458057710
|
|
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
|
|
|
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 00781730431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.55 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
|
|
RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH [82504]
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
NDC 00781730431
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.93 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.85
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.93
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: University Health Alliance Commercial |
$31.34
|
|
