|
OVERTUBE ENDOSCOPIC ACCESS
|
Facility
|
IP
|
$798.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$678.30 |
| Max. Negotiated Rate |
$774.06 |
| Rate for Payer: Cash Price |
$478.80
|
| Rate for Payer: Health Management Network Commercial |
$678.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$718.20
|
| Rate for Payer: MDX Hawaii PPO |
$774.06
|
|
|
OVOMATION 56X52MM 8HM2-5652-A
|
Facility
|
OP
|
$8,670.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,335.00 |
| Max. Negotiated Rate |
$8,409.90 |
| Rate for Payer: Kaiser Permanente Medicare |
$6,589.20
|
| Rate for Payer: AlohaCare Medicaid |
$4,335.00
|
| Rate for Payer: AlohaCare Medicare |
$6,589.20
|
| Rate for Payer: Cash Price |
$5,202.00
|
| Rate for Payer: Devoted Health Medicare |
$7,282.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,589.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,069.00
|
| Rate for Payer: Health Management Network Commercial |
$7,369.50
|
| Rate for Payer: Humana Medicare |
$6,589.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,803.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,421.70
|
| Rate for Payer: MDX Hawaii PPO |
$8,409.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,589.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,589.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,589.20
|
| Rate for Payer: University Health Alliance Commercial |
$4,855.20
|
|
|
OVOMATION 56X52MM 8HM2-5652-A
|
Facility
|
IP
|
$8,670.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,855.20 |
| Max. Negotiated Rate |
$8,409.90 |
| Rate for Payer: Cash Price |
$5,202.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,069.00
|
| Rate for Payer: Health Management Network Commercial |
$7,369.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,803.00
|
| Rate for Payer: MDX Hawaii PPO |
$8,409.90
|
| Rate for Payer: University Health Alliance Commercial |
$4,855.20
|
|
|
OVOMOTION SHOULDER SYS 54X50MM
|
Facility
|
IP
|
$8,670.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,855.20 |
| Max. Negotiated Rate |
$8,409.90 |
| Rate for Payer: Cash Price |
$5,202.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,069.00
|
| Rate for Payer: Health Management Network Commercial |
$7,369.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,803.00
|
| Rate for Payer: MDX Hawaii PPO |
$8,409.90
|
| Rate for Payer: University Health Alliance Commercial |
$4,855.20
|
|
|
OVOMOTION SHOULDER SYS 54X50MM
|
Facility
|
OP
|
$8,670.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,335.00 |
| Max. Negotiated Rate |
$8,409.90 |
| Rate for Payer: AlohaCare Medicaid |
$4,335.00
|
| Rate for Payer: AlohaCare Medicare |
$6,589.20
|
| Rate for Payer: Cash Price |
$5,202.00
|
| Rate for Payer: Devoted Health Medicare |
$7,282.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,589.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,069.00
|
| Rate for Payer: Health Management Network Commercial |
$7,369.50
|
| Rate for Payer: Humana Medicare |
$6,589.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,803.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,421.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,589.20
|
| Rate for Payer: MDX Hawaii PPO |
$8,409.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,589.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,589.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,589.20
|
| Rate for Payer: University Health Alliance Commercial |
$4,855.20
|
|
|
OXACILLIN 10 GRAM SOLUTION FOR INJECTION [171652]
|
Facility
|
IP
|
$211.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$179.35 |
| Max. Negotiated Rate |
$204.67 |
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Health Management Network Commercial |
$179.35
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
| Rate for Payer: MDX Hawaii PPO |
$204.67
|
|
|
OXACILLIN 10 GRAM SOLUTION FOR INJECTION [171652]
|
Facility
|
OP
|
$211.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$204.67 |
| Rate for Payer: AlohaCare Medicaid |
$105.50
|
| Rate for Payer: AlohaCare Medicaid |
$109.00
|
| Rate for Payer: AlohaCare Medicare |
$165.68
|
| Rate for Payer: AlohaCare Medicare |
$160.36
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$126.60
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Devoted Health Medicare |
$177.24
|
| Rate for Payer: Devoted Health Medicare |
$183.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$165.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$160.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$200.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.10
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Health Management Network Commercial |
$179.35
|
| Rate for Payer: Humana Medicare |
$160.36
|
| Rate for Payer: Humana Medicare |
$165.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$160.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$165.68
|
| Rate for Payer: MDX Hawaii PPO |
$204.67
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$165.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$160.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$160.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$165.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$130.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$126.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$160.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$165.68
|
| Rate for Payer: University Health Alliance Commercial |
$153.80
|
| Rate for Payer: University Health Alliance Commercial |
$158.90
|
|
|
OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
OXACILLIN 1 GRAM SOLUTION FOR INJECTION [5924]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicare |
$28.12
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$31.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.15
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Humana Medicare |
$28.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.12
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.12
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
| Rate for Payer: University Health Alliance Commercial |
$26.97
|
|
|
OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicaid |
$35.50
|
| Rate for Payer: AlohaCare Medicare |
$53.96
|
| Rate for Payer: AlohaCare Medicare |
$25.08
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Devoted Health Medicare |
$27.72
|
| Rate for Payer: Devoted Health Medicare |
$59.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.45
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$25.08
|
| Rate for Payer: Humana Medicare |
$53.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.96
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.96
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
| Rate for Payer: University Health Alliance Commercial |
$51.75
|
|
|
OXACILLIN 2 GRAM SOLUTION FOR INJECTION [5926]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
OXACILLIN SODIUM 10 G/100ML IV (WET SOLR VIAL) [430171652]
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$211.46 |
| Rate for Payer: AlohaCare Medicaid |
$109.00
|
| Rate for Payer: AlohaCare Medicaid |
$130.50
|
| Rate for Payer: AlohaCare Medicare |
$198.36
|
| Rate for Payer: AlohaCare Medicare |
$165.68
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Devoted Health Medicare |
$183.12
|
| Rate for Payer: Devoted Health Medicare |
$219.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$198.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$165.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$207.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$247.95
|
| Rate for Payer: Health Management Network Commercial |
$221.85
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Humana Medicare |
$165.68
|
| Rate for Payer: Humana Medicare |
$198.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$133.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$111.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$165.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$198.36
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
| Rate for Payer: MDX Hawaii PPO |
$253.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$198.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$165.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$165.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$198.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$156.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$130.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$165.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$198.36
|
| Rate for Payer: University Health Alliance Commercial |
$158.90
|
| Rate for Payer: University Health Alliance Commercial |
$190.24
|
|
|
OXACILLIN SODIUM 10 G/100ML IV (WET SOLR VIAL) [430171652]
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$185.30 |
| Max. Negotiated Rate |
$211.46 |
| Rate for Payer: Cash Price |
$130.80
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Health Management Network Commercial |
$185.30
|
| Rate for Payer: Health Management Network Commercial |
$221.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$196.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.90
|
| Rate for Payer: MDX Hawaii PPO |
$253.17
|
| Rate for Payer: MDX Hawaii PPO |
$211.46
|
|
|
OXACILLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4305924]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$25.08
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Devoted Health Medicare |
$27.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Humana Medicare |
$25.08
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
OXACILLIN SODIUM 1 G/10ML IJ (WET SOLR VIAL) [4305924]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
OXACILLIN SODIUM 2 G/20ML IJ (WET SOLR VIAL) [4305926]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$25.08
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$27.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$25.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.08
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.08
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
OXACILLIN SODIUM 2 G/20ML IJ (WET SOLR VIAL) [4305926]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS J2700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS J9263
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$271.80
|
| Rate for Payer: Health Management Network Commercial |
$385.05
|
| Rate for Payer: Health Management Network Commercial |
$306.00
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$324.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$407.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$349.20
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$439.41
|
|
|
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION [99612]
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS J9263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$349.20 |
| Rate for Payer: AlohaCare Medicaid |
$180.00
|
| Rate for Payer: AlohaCare Medicaid |
$226.50
|
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: AlohaCare Medicare |
$79.80
|
| Rate for Payer: AlohaCare Medicare |
$273.60
|
| Rate for Payer: AlohaCare Medicare |
$344.28
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$271.80
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cash Price |
$271.80
|
| Rate for Payer: Devoted Health Medicare |
$380.52
|
| Rate for Payer: Devoted Health Medicare |
$302.40
|
| Rate for Payer: Devoted Health Medicare |
$70.56
|
| Rate for Payer: Devoted Health Medicare |
$88.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$79.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$344.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$430.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$99.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$342.00
|
| Rate for Payer: Health Management Network Commercial |
$385.05
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Health Management Network Commercial |
$306.00
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Humana Medicare |
$79.80
|
| Rate for Payer: Humana Medicare |
$344.28
|
| Rate for Payer: Humana Medicare |
$273.60
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$407.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$324.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$183.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$231.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$344.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$79.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.60
|
| Rate for Payer: MDX Hawaii PPO |
$439.41
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$349.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$273.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$344.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$79.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$344.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$273.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$79.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$216.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$271.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$79.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$344.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.60
|
| Rate for Payer: University Health Alliance Commercial |
$76.53
|
| Rate for Payer: University Health Alliance Commercial |
$262.40
|
| Rate for Payer: University Health Alliance Commercial |
$330.19
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS J9263
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$162.00
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
|
|
OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [99610]
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS J9263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$101.85 |
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicaid |
$90.00
|
| Rate for Payer: AlohaCare Medicare |
$136.80
|
| Rate for Payer: AlohaCare Medicare |
$79.80
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Devoted Health Medicare |
$88.20
|
| Rate for Payer: Devoted Health Medicare |
$151.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$136.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$79.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$99.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$171.00
|
| Rate for Payer: Health Management Network Commercial |
$153.00
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Humana Medicare |
$79.80
|
| Rate for Payer: Humana Medicare |
$136.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$162.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$79.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$136.80
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$174.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$136.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$79.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$79.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$136.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$108.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$79.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$136.80
|
| Rate for Payer: University Health Alliance Commercial |
$76.53
|
| Rate for Payer: University Health Alliance Commercial |
$131.20
|
|
|
OX ANAT BRG SIZE 4 PMA 159548
|
Facility
|
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,200.00
|
| Rate for Payer: AlohaCare Medicare |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Devoted Health Medicare |
$2,016.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,824.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: Humana Medicare |
$1,824.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,160.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,224.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,824.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,824.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,824.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,824.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
OX ANAT BRG SIZE 4 PMA 159548
|
Facility
|
IP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,344.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,160.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
OXF ANAT BRG LT GL SZ-3 159554
|
Facility
|
IP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,344.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,160.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
|
OXF ANAT BRG LT GL SZ-3 159554
|
Facility
|
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$2,328.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,200.00
|
| Rate for Payer: AlohaCare Medicare |
$1,824.00
|
| Rate for Payer: Cash Price |
$1,440.00
|
| Rate for Payer: Devoted Health Medicare |
$2,016.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,824.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,680.00
|
| Rate for Payer: Health Management Network Commercial |
$2,040.00
|
| Rate for Payer: Humana Medicare |
$1,824.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,160.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,224.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,824.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,328.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,824.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,824.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,824.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,344.00
|
|
