|
PALINDROME SPORT KIT
|
Facility
|
OP
|
$1,470.00
|
|
|
Service Code
|
HCPCS C1750
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$735.00 |
| Max. Negotiated Rate |
$1,425.90 |
| Rate for Payer: AlohaCare Medicaid |
$735.00
|
| Rate for Payer: AlohaCare Medicare |
$1,117.20
|
| Rate for Payer: Cash Price |
$882.00
|
| Rate for Payer: Devoted Health Medicare |
$1,234.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,117.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,396.50
|
| Rate for Payer: Health Management Network Commercial |
$1,249.50
|
| Rate for Payer: Humana Medicare |
$1,117.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,323.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$749.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,117.20
|
| Rate for Payer: MDX Hawaii PPO |
$1,425.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,117.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,117.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,117.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,071.48
|
|
|
PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [78064]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 27808022301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
|
|
PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR [78064]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 27808022301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicare |
$58.52
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Devoted Health Medicare |
$64.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.15
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Humana Medicare |
$58.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.52
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.52
|
| Rate for Payer: University Health Alliance Commercial |
$56.13
|
|
|
PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR [78065]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 65162028203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicare |
$58.52
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Devoted Health Medicare |
$64.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.15
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Humana Medicare |
$58.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.52
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.52
|
| Rate for Payer: University Health Alliance Commercial |
$56.13
|
|
|
PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR [78065]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 65162028203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
|
|
PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR [78065]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
NDC 27808022401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.45 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
|
|
PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR [78065]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
NDC 27808022401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$74.69 |
| Rate for Payer: AlohaCare Medicaid |
$38.50
|
| Rate for Payer: AlohaCare Medicare |
$58.52
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: Devoted Health Medicare |
$64.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.15
|
| Rate for Payer: Health Management Network Commercial |
$65.45
|
| Rate for Payer: Humana Medicare |
$58.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$58.52
|
| Rate for Payer: MDX Hawaii PPO |
$74.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$58.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.52
|
| Rate for Payer: University Health Alliance Commercial |
$56.13
|
|
|
PALIPERIDONE PALMITATE 117 MG/0.75 ML INTRAMUSCULAR SYRINGE [166236]
|
Facility
|
IP
|
$2,642.00
|
|
|
Service Code
|
HCPCS J2426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,245.70 |
| Max. Negotiated Rate |
$2,562.74 |
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Health Management Network Commercial |
$2,245.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,377.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,562.74
|
|
|
PALIPERIDONE PALMITATE 117 MG/0.75 ML INTRAMUSCULAR SYRINGE [166236]
|
Facility
|
OP
|
$2,642.00
|
|
|
Service Code
|
HCPCS J2426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$2,562.74 |
| Rate for Payer: AlohaCare Medicaid |
$1,321.00
|
| Rate for Payer: AlohaCare Medicare |
$2,007.92
|
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Cash Price |
$1,585.20
|
| Rate for Payer: Devoted Health Medicare |
$2,219.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.08
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,007.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$15.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,509.90
|
| Rate for Payer: Health Management Network Commercial |
$2,245.70
|
| Rate for Payer: Humana Medicare |
$2,007.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,377.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,347.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,007.92
|
| Rate for Payer: MDX Hawaii PPO |
$2,562.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,007.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,007.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,585.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,007.92
|
| Rate for Payer: University Health Alliance Commercial |
$1,925.75
|
|
|
PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION [36591]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS J2469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$357.00
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$378.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$407.40
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION [36591]
|
Facility
|
OP
|
$420.00
|
|
|
Service Code
|
HCPCS J2469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$407.40 |
| Rate for Payer: AlohaCare Medicaid |
$210.00
|
| Rate for Payer: AlohaCare Medicaid |
$38.00
|
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$95.76
|
| Rate for Payer: AlohaCare Medicare |
$28.88
|
| Rate for Payer: AlohaCare Medicare |
$319.20
|
| Rate for Payer: AlohaCare Medicare |
$57.76
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Devoted Health Medicare |
$31.92
|
| Rate for Payer: Devoted Health Medicare |
$352.80
|
| Rate for Payer: Devoted Health Medicare |
$105.84
|
| Rate for Payer: Devoted Health Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$319.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$399.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.20
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$357.00
|
| Rate for Payer: Humana Medicare |
$28.88
|
| Rate for Payer: Humana Medicare |
$95.76
|
| Rate for Payer: Humana Medicare |
$319.20
|
| Rate for Payer: Humana Medicare |
$57.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$378.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$214.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$319.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.76
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
| Rate for Payer: MDX Hawaii PPO |
$407.40
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$319.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$319.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$252.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$319.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.76
|
| Rate for Payer: University Health Alliance Commercial |
$55.40
|
| Rate for Payer: University Health Alliance Commercial |
$306.14
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION [32589]
|
Facility
|
OP
|
$114.00
|
|
|
Service Code
|
HCPCS J2430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: AlohaCare Medicaid |
$57.00
|
| Rate for Payer: AlohaCare Medicaid |
$41.00
|
| Rate for Payer: AlohaCare Medicare |
$62.32
|
| Rate for Payer: AlohaCare Medicare |
$86.64
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Devoted Health Medicare |
$95.76
|
| Rate for Payer: Devoted Health Medicare |
$68.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$86.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.90
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Humana Medicare |
$86.64
|
| Rate for Payer: Humana Medicare |
$62.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$86.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.32
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$86.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$86.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$86.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.32
|
| Rate for Payer: University Health Alliance Commercial |
$83.09
|
| Rate for Payer: University Health Alliance Commercial |
$59.77
|
|
|
PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION [32589]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS J2430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
|
|
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION [32855]
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
HCPCS J2430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$272.57 |
| Rate for Payer: AlohaCare Medicaid |
$140.50
|
| Rate for Payer: AlohaCare Medicare |
$213.56
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Devoted Health Medicare |
$236.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$213.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$266.95
|
| Rate for Payer: Health Management Network Commercial |
$238.85
|
| Rate for Payer: Humana Medicare |
$213.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$252.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$143.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$213.56
|
| Rate for Payer: MDX Hawaii PPO |
$272.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$213.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$213.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$168.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$213.56
|
| Rate for Payer: University Health Alliance Commercial |
$204.82
|
|
|
PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION [32855]
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
HCPCS J2430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$238.85 |
| Max. Negotiated Rate |
$272.57 |
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Health Management Network Commercial |
$238.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$252.90
|
| Rate for Payer: MDX Hawaii PPO |
$272.57
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC
|
Facility
|
IP
|
$51,646.66
|
|
|
Service Code
|
MSDRG 406
|
| Min. Negotiated Rate |
$51,646.66 |
| Max. Negotiated Rate |
$51,646.66 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$51,646.66
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC
|
Facility
|
IP
|
$93,433.28
|
|
|
Service Code
|
MSDRG 405
|
| Min. Negotiated Rate |
$93,433.28 |
| Max. Negotiated Rate |
$93,433.28 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$93,433.28
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$37,022.52
|
|
|
Service Code
|
MSDRG 407
|
| Min. Negotiated Rate |
$37,022.52 |
| Max. Negotiated Rate |
$37,022.52 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37,022.52
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$10,400.00
|
|
|
Service Code
|
MSDRG 010
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$10,400.00 |
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION [108055]
|
Facility
|
OP
|
$3,261.00
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.55 |
| Max. Negotiated Rate |
$3,163.17 |
| Rate for Payer: AlohaCare Medicaid |
$1,630.50
|
| Rate for Payer: AlohaCare Medicaid |
$4,207.00
|
| Rate for Payer: AlohaCare Medicare |
$6,394.64
|
| Rate for Payer: AlohaCare Medicare |
$2,478.36
|
| Rate for Payer: Cash Price |
$1,956.60
|
| Rate for Payer: Cash Price |
$1,956.60
|
| Rate for Payer: Cash Price |
$5,048.40
|
| Rate for Payer: Cash Price |
$5,048.40
|
| Rate for Payer: Devoted Health Medicare |
$2,739.24
|
| Rate for Payer: Devoted Health Medicare |
$7,067.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$172.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$172.55
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$217.99
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$217.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,478.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,394.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$172.55
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$172.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,097.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,993.30
|
| Rate for Payer: Health Management Network Commercial |
$2,771.85
|
| Rate for Payer: Health Management Network Commercial |
$7,151.90
|
| Rate for Payer: Humana Medicare |
$2,478.36
|
| Rate for Payer: Humana Medicare |
$6,394.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,934.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,572.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,663.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,291.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,478.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,394.64
|
| Rate for Payer: MDX Hawaii PPO |
$3,163.17
|
| Rate for Payer: MDX Hawaii PPO |
$8,161.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,394.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,478.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,478.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,394.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,956.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,048.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,394.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,478.36
|
| Rate for Payer: University Health Alliance Commercial |
$2,376.94
|
| Rate for Payer: University Health Alliance Commercial |
$6,132.96
|
|
|
PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION [108055]
|
Facility
|
IP
|
$3,261.00
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,771.85 |
| Max. Negotiated Rate |
$3,163.17 |
| Rate for Payer: Cash Price |
$1,956.60
|
| Rate for Payer: Cash Price |
$5,048.40
|
| Rate for Payer: Health Management Network Commercial |
$7,151.90
|
| Rate for Payer: Health Management Network Commercial |
$2,771.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,934.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,572.60
|
| Rate for Payer: MDX Hawaii PPO |
$3,163.17
|
| Rate for Payer: MDX Hawaii PPO |
$8,161.58
|
|
|
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [108057]
|
Facility
|
IP
|
$13,044.00
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,087.40 |
| Max. Negotiated Rate |
$12,652.68 |
| Rate for Payer: Cash Price |
$7,826.40
|
| Rate for Payer: Health Management Network Commercial |
$11,087.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,739.60
|
| Rate for Payer: MDX Hawaii PPO |
$12,652.68
|
|
|
PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION [108057]
|
Facility
|
OP
|
$13,044.00
|
|
|
Service Code
|
HCPCS J9303
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$172.55 |
| Max. Negotiated Rate |
$12,652.68 |
| Rate for Payer: AlohaCare Medicaid |
$6,522.00
|
| Rate for Payer: AlohaCare Medicare |
$9,913.44
|
| Rate for Payer: Cash Price |
$7,826.40
|
| Rate for Payer: Cash Price |
$7,826.40
|
| Rate for Payer: Devoted Health Medicare |
$10,956.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$172.55
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$217.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,913.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$172.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,391.80
|
| Rate for Payer: Health Management Network Commercial |
$11,087.40
|
| Rate for Payer: Humana Medicare |
$9,913.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,739.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,652.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,913.44
|
| Rate for Payer: MDX Hawaii PPO |
$12,652.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,913.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,913.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,826.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,913.44
|
| Rate for Payer: University Health Alliance Commercial |
$9,507.77
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 55150020210
|
|
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: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION [26226]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00143928410
|
|
Hospital Revenue Code
|
250
|
| 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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
