|
MISOPROSTOL 25 MCG QUARTER TABLET [400620]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 09999701554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
OP
|
$2,276.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$2,207.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,138.00
|
| Rate for Payer: AlohaCare Medicaid |
$405.00
|
| Rate for Payer: AlohaCare Medicaid |
$569.00
|
| Rate for Payer: AlohaCare Medicare |
$615.60
|
| Rate for Payer: AlohaCare Medicare |
$1,729.76
|
| Rate for Payer: AlohaCare Medicare |
$864.88
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$1,365.60
|
| Rate for Payer: Cash Price |
$1,365.60
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Devoted Health Medicare |
$680.40
|
| Rate for Payer: Devoted Health Medicare |
$955.92
|
| Rate for Payer: Devoted Health Medicare |
$1,911.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$615.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$864.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,729.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,081.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$769.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,162.20
|
| Rate for Payer: Health Management Network Commercial |
$967.30
|
| Rate for Payer: Health Management Network Commercial |
$688.50
|
| Rate for Payer: Health Management Network Commercial |
$1,934.60
|
| Rate for Payer: Humana Medicare |
$615.60
|
| Rate for Payer: Humana Medicare |
$1,729.76
|
| Rate for Payer: Humana Medicare |
$864.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$729.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,048.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,024.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,160.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$580.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$413.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$864.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,729.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$615.60
|
| Rate for Payer: MDX Hawaii PPO |
$785.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,103.86
|
| Rate for Payer: MDX Hawaii PPO |
$2,207.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$864.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,729.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$615.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$615.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,729.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$864.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$682.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,365.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$486.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,729.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$864.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$615.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,658.98
|
| Rate for Payer: University Health Alliance Commercial |
$590.41
|
| Rate for Payer: University Health Alliance Commercial |
$829.49
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$688.50 |
| Max. Negotiated Rate |
$785.70 |
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$1,365.60
|
| Rate for Payer: Health Management Network Commercial |
$688.50
|
| Rate for Payer: Health Management Network Commercial |
$1,934.60
|
| Rate for Payer: Health Management Network Commercial |
$967.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,024.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,048.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$729.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,207.72
|
| Rate for Payer: MDX Hawaii PPO |
$1,103.86
|
| Rate for Payer: MDX Hawaii PPO |
$785.70
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,445.00 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cash Price |
$1,210.20
|
| Rate for Payer: Health Management Network Commercial |
$1,445.00
|
| Rate for Payer: Health Management Network Commercial |
$1,714.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,530.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,815.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,956.49
|
| Rate for Payer: MDX Hawaii PPO |
$1,649.00
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: AlohaCare Medicaid |
$850.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,008.50
|
| Rate for Payer: AlohaCare Medicare |
$1,532.92
|
| Rate for Payer: AlohaCare Medicare |
$1,292.00
|
| Rate for Payer: Cash Price |
$1,210.20
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cash Price |
$1,210.20
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Devoted Health Medicare |
$1,428.00
|
| Rate for Payer: Devoted Health Medicare |
$1,694.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,532.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,292.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,615.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,916.15
|
| Rate for Payer: Health Management Network Commercial |
$1,714.45
|
| Rate for Payer: Health Management Network Commercial |
$1,445.00
|
| Rate for Payer: Humana Medicare |
$1,292.00
|
| Rate for Payer: Humana Medicare |
$1,532.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,530.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,815.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,028.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$867.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,292.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,532.92
|
| Rate for Payer: MDX Hawaii PPO |
$1,649.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,956.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,532.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,292.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,292.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,532.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,210.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,020.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,292.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,532.92
|
| Rate for Payer: University Health Alliance Commercial |
$1,239.13
|
| Rate for Payer: University Health Alliance Commercial |
$1,470.19
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL COMPOUNDED [4080435]
|
Facility
|
IP
|
$25,845.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21,968.25 |
| Max. Negotiated Rate |
$25,069.65 |
| Rate for Payer: Cash Price |
$15,507.00
|
| Rate for Payer: Health Management Network Commercial |
$21,968.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$23,260.50
|
| Rate for Payer: MDX Hawaii PPO |
$25,069.65
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL COMPOUNDED [4080435]
|
Facility
|
OP
|
$25,845.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.42 |
| Max. Negotiated Rate |
$25,069.65 |
| Rate for Payer: AlohaCare Medicaid |
$12,922.50
|
| Rate for Payer: AlohaCare Medicare |
$19,642.20
|
| Rate for Payer: Cash Price |
$15,507.00
|
| Rate for Payer: Cash Price |
$15,507.00
|
| Rate for Payer: Devoted Health Medicare |
$21,709.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$317.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$403.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19,642.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$317.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24,552.75
|
| Rate for Payer: Health Management Network Commercial |
$21,968.25
|
| Rate for Payer: Humana Medicare |
$19,642.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$23,260.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13,180.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$19,642.20
|
| Rate for Payer: MDX Hawaii PPO |
$25,069.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19,642.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$19,642.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15,507.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19,642.20
|
| Rate for Payer: University Health Alliance Commercial |
$18,838.42
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [173366]
|
Facility
|
IP
|
$30,434.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25,868.90 |
| Max. Negotiated Rate |
$29,520.98 |
| Rate for Payer: Cash Price |
$18,260.40
|
| Rate for Payer: Health Management Network Commercial |
$25,868.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$27,390.60
|
| Rate for Payer: MDX Hawaii PPO |
$29,520.98
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [173366]
|
Facility
|
OP
|
$30,434.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.42 |
| Max. Negotiated Rate |
$29,520.98 |
| Rate for Payer: AlohaCare Medicaid |
$15,217.00
|
| Rate for Payer: AlohaCare Medicare |
$23,129.84
|
| Rate for Payer: Cash Price |
$18,260.40
|
| Rate for Payer: Cash Price |
$18,260.40
|
| Rate for Payer: Devoted Health Medicare |
$25,564.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$317.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$403.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23,129.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$317.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28,912.30
|
| Rate for Payer: Health Management Network Commercial |
$25,868.90
|
| Rate for Payer: Humana Medicare |
$23,129.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$27,390.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15,521.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$23,129.84
|
| Rate for Payer: MDX Hawaii PPO |
$29,520.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23,129.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$23,129.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18,260.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$23,129.84
|
| Rate for Payer: University Health Alliance Commercial |
$22,183.34
|
|
|
MITOMYCIN 5 MG/10ML IV (WET SOLR VIAL) [43010632]
|
Facility
|
OP
|
$409.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$396.73 |
| Rate for Payer: AlohaCare Medicaid |
$204.50
|
| Rate for Payer: AlohaCare Medicare |
$310.84
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Devoted Health Medicare |
$343.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$310.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$388.55
|
| Rate for Payer: Health Management Network Commercial |
$347.65
|
| Rate for Payer: Humana Medicare |
$310.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$368.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$208.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$310.84
|
| Rate for Payer: MDX Hawaii PPO |
$396.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$310.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$245.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$310.84
|
| Rate for Payer: University Health Alliance Commercial |
$298.12
|
|
|
MITOMYCIN 5 MG/10ML IV (WET SOLR VIAL) [43010632]
|
Facility
|
IP
|
$409.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$347.65 |
| Max. Negotiated Rate |
$396.73 |
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Health Management Network Commercial |
$347.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$368.10
|
| Rate for Payer: MDX Hawaii PPO |
$396.73
|
|
|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$1,173.70 |
| Rate for Payer: AlohaCare Medicaid |
$605.00
|
| Rate for Payer: AlohaCare Medicaid |
$204.50
|
| Rate for Payer: AlohaCare Medicare |
$310.84
|
| Rate for Payer: AlohaCare Medicare |
$919.60
|
| Rate for Payer: Cash Price |
$726.00
|
| Rate for Payer: Cash Price |
$726.00
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Devoted Health Medicare |
$1,016.40
|
| Rate for Payer: Devoted Health Medicare |
$343.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$919.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$310.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,149.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$388.55
|
| Rate for Payer: Health Management Network Commercial |
$1,028.50
|
| Rate for Payer: Health Management Network Commercial |
$347.65
|
| Rate for Payer: Humana Medicare |
$919.60
|
| Rate for Payer: Humana Medicare |
$310.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,089.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$368.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$617.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$208.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$919.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$310.84
|
| Rate for Payer: MDX Hawaii PPO |
$1,173.70
|
| Rate for Payer: MDX Hawaii PPO |
$396.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$310.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$919.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$919.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$310.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$726.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$245.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$310.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$919.60
|
| Rate for Payer: University Health Alliance Commercial |
$881.97
|
| Rate for Payer: University Health Alliance Commercial |
$298.12
|
|
|
MITOMYCIN 5 MG INTRAVENOUS SOLUTION [10632]
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,028.50 |
| Max. Negotiated Rate |
$1,173.70 |
| Rate for Payer: Cash Price |
$726.00
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Health Management Network Commercial |
$347.65
|
| Rate for Payer: Health Management Network Commercial |
$1,028.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,089.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$368.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,173.70
|
| Rate for Payer: MDX Hawaii PPO |
$396.73
|
|
|
M/L TAPER 9 STD 00-7711-009-00
|
Facility
|
IP
|
$5,200.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,912.00 |
| Max. Negotiated Rate |
$5,044.00 |
| Rate for Payer: Cash Price |
$3,120.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,640.00
|
| Rate for Payer: Health Management Network Commercial |
$4,420.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,680.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,044.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,912.00
|
|
|
M/L TAPER 9 STD 00-7711-009-00
|
Facility
|
OP
|
$5,200.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,600.00 |
| Max. Negotiated Rate |
$5,044.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,600.00
|
| Rate for Payer: AlohaCare Medicare |
$3,952.00
|
| Rate for Payer: Cash Price |
$3,120.00
|
| Rate for Payer: Devoted Health Medicare |
$4,368.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,952.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,640.00
|
| Rate for Payer: Health Management Network Commercial |
$4,420.00
|
| Rate for Payer: Humana Medicare |
$3,952.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,680.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,652.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,952.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,044.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,952.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,952.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,952.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,912.00
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 00904679104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$21.28
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$23.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$21.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.28
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 68084062121
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicare |
$50.16
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Devoted Health Medicare |
$55.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$50.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Humana Medicare |
$50.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.16
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$50.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$50.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$50.16
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 68084062121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
MODAFINIL 100 MG TABLET [24702]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00904679104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
MODIFIED LANOLIN 100 % TOPICAL CREAM [170446]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 10202000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$7.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$8.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$7.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.60
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.60
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
MODIFIED LANOLIN 100 % TOPICAL CREAM [170446]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 10202000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
MODULAR FLEX DRILL BIT 30MM
|
Facility
|
OP
|
$818.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$409.00 |
| Max. Negotiated Rate |
$793.46 |
| Rate for Payer: AlohaCare Medicaid |
$409.00
|
| Rate for Payer: AlohaCare Medicare |
$621.68
|
| Rate for Payer: Cash Price |
$490.80
|
| Rate for Payer: Devoted Health Medicare |
$687.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$621.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$777.10
|
| Rate for Payer: Health Management Network Commercial |
$695.30
|
| Rate for Payer: Humana Medicare |
$621.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$736.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$417.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$621.68
|
| Rate for Payer: MDX Hawaii PPO |
$793.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$621.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$621.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$621.68
|
| Rate for Payer: University Health Alliance Commercial |
$596.24
|
|
|
MODULAR FLEX DRILL BIT 30MM
|
Facility
|
IP
|
$818.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$695.30 |
| Max. Negotiated Rate |
$793.46 |
| Rate for Payer: Cash Price |
$490.80
|
| Rate for Payer: Health Management Network Commercial |
$695.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$736.20
|
| Rate for Payer: MDX Hawaii PPO |
$793.46
|
|
|
MODULAR HIIP SYS 6276-1-025
|
Facility
|
IP
|
$8,969.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,022.64 |
| Max. Negotiated Rate |
$8,699.93 |
| Rate for Payer: Cash Price |
$5,381.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,278.30
|
| Rate for Payer: Health Management Network Commercial |
$7,623.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,072.10
|
| Rate for Payer: MDX Hawaii PPO |
$8,699.93
|
| Rate for Payer: University Health Alliance Commercial |
$5,022.64
|
|
|
MODULAR HIIP SYS 6276-1-025
|
Facility
|
OP
|
$8,969.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,484.50 |
| Max. Negotiated Rate |
$8,699.93 |
| Rate for Payer: AlohaCare Medicaid |
$4,484.50
|
| Rate for Payer: AlohaCare Medicare |
$6,816.44
|
| Rate for Payer: Cash Price |
$5,381.40
|
| Rate for Payer: Devoted Health Medicare |
$7,533.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,816.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,278.30
|
| Rate for Payer: Health Management Network Commercial |
$7,623.65
|
| Rate for Payer: Humana Medicare |
$6,816.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,072.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,574.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,816.44
|
| Rate for Payer: MDX Hawaii PPO |
$8,699.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,816.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,816.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,816.44
|
| Rate for Payer: University Health Alliance Commercial |
$5,022.64
|
|
