|
CXP PRECONNECT TENACIO 21CM
|
Facility
|
IP
|
$29,515.00
|
|
|
Service Code
|
HCPCS C1813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$16,528.40 |
| Max. Negotiated Rate |
$28,629.55 |
| Rate for Payer: Cash Price |
$17,709.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,660.50
|
| Rate for Payer: Health Management Network Commercial |
$25,087.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$26,563.50
|
| Rate for Payer: MDX Hawaii PPO |
$28,629.55
|
| Rate for Payer: University Health Alliance Commercial |
$16,528.40
|
|
|
CXP PRECONNECT TENACIO 21CM
|
Facility
|
OP
|
$29,515.00
|
|
|
Service Code
|
HCPCS C1813
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,149.65 |
| Max. Negotiated Rate |
$28,629.55 |
| Rate for Payer: AlohaCare Medicaid |
$14,757.50
|
| Rate for Payer: AlohaCare Medicare |
$9,149.65
|
| Rate for Payer: Cash Price |
$17,709.00
|
| Rate for Payer: Devoted Health Medicare |
$10,035.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,149.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,660.50
|
| Rate for Payer: Health Management Network Commercial |
$25,087.75
|
| Rate for Payer: Humana Medicare |
$9,149.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$26,563.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15,052.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,149.65
|
| Rate for Payer: MDX Hawaii PPO |
$28,629.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,149.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,149.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,149.65
|
| Rate for Payer: University Health Alliance Commercial |
$16,528.40
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION [2007]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J3420
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| 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 |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687055801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 69097084607
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687055811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687055811
|
|
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
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687055801
|
|
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
|
|
|
CYCLOBENZAPRINE 10 MG TABLET [2017]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 69097084607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
CYCLOBENZAPRINE TABLETS (FLEXERIL) 10 MG (TAKE HOME) [4080352]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080140
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CYCLOBENZAPRINE TABLETS (FLEXERIL) 10 MG (TAKE HOME) [4080352]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080140
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 61314039601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$15.81
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$15.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.81
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
CYCLOPENTOLATE 1 % EYE DROPS [2025]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 61314039601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [174600]
|
Facility
|
OP
|
$2,110.00
|
|
|
Service Code
|
HCPCS J9073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2,046.70 |
| Rate for Payer: AlohaCare Medicaid |
$1,055.00
|
| Rate for Payer: AlohaCare Medicaid |
$659.50
|
| Rate for Payer: AlohaCare Medicaid |
$585.50
|
| Rate for Payer: AlohaCare Medicaid |
$527.50
|
| Rate for Payer: AlohaCare Medicare |
$363.01
|
| Rate for Payer: AlohaCare Medicare |
$408.89
|
| Rate for Payer: AlohaCare Medicare |
$327.05
|
| Rate for Payer: AlohaCare Medicare |
$654.10
|
| Rate for Payer: Cash Price |
$1,266.00
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$1,266.00
|
| Rate for Payer: Cash Price |
$791.40
|
| Rate for Payer: Cash Price |
$791.40
|
| Rate for Payer: Devoted Health Medicare |
$717.40
|
| Rate for Payer: Devoted Health Medicare |
$448.46
|
| Rate for Payer: Devoted Health Medicare |
$398.14
|
| Rate for Payer: Devoted Health Medicare |
$358.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$654.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$408.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$327.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$363.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,253.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,002.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,112.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,004.50
|
| Rate for Payer: Health Management Network Commercial |
$1,121.15
|
| Rate for Payer: Health Management Network Commercial |
$1,793.50
|
| Rate for Payer: Health Management Network Commercial |
$995.35
|
| Rate for Payer: Health Management Network Commercial |
$896.75
|
| Rate for Payer: Humana Medicare |
$327.05
|
| Rate for Payer: Humana Medicare |
$408.89
|
| Rate for Payer: Humana Medicare |
$363.01
|
| Rate for Payer: Humana Medicare |
$654.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,899.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,187.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,053.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$949.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$672.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$597.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$538.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,076.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$408.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$363.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$327.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$654.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,023.35
|
| Rate for Payer: MDX Hawaii PPO |
$1,135.87
|
| Rate for Payer: MDX Hawaii PPO |
$2,046.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,279.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$327.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$408.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$654.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$363.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$408.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$327.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$363.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$654.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$633.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,266.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$791.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$702.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$408.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$327.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$654.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$363.01
|
| Rate for Payer: University Health Alliance Commercial |
$768.99
|
| Rate for Payer: University Health Alliance Commercial |
$961.42
|
| Rate for Payer: University Health Alliance Commercial |
$1,537.98
|
| Rate for Payer: University Health Alliance Commercial |
$853.54
|
|
|
CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [174600]
|
Facility
|
IP
|
$1,171.00
|
|
|
Service Code
|
HCPCS J9073
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$995.35 |
| Max. Negotiated Rate |
$1,135.87 |
| Rate for Payer: Cash Price |
$702.60
|
| Rate for Payer: Cash Price |
$1,266.00
|
| Rate for Payer: Cash Price |
$791.40
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Health Management Network Commercial |
$995.35
|
| Rate for Payer: Health Management Network Commercial |
$1,793.50
|
| Rate for Payer: Health Management Network Commercial |
$896.75
|
| Rate for Payer: Health Management Network Commercial |
$1,121.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,899.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$949.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,053.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,187.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,046.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,023.35
|
| Rate for Payer: MDX Hawaii PPO |
$1,135.87
|
| Rate for Payer: MDX Hawaii PPO |
$1,279.43
|
|
|
CYCLOPHOSPHAMIDE 50 MG CAPSULE [126405]
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS J8530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
CYCLOPHOSPHAMIDE 50 MG CAPSULE [126405]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J8530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicaid |
$22.50
|
| Rate for Payer: AlohaCare Medicare |
$13.95
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Devoted Health Medicare |
$15.30
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Humana Medicare |
$13.95
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
| Rate for Payer: University Health Alliance Commercial |
$32.80
|
|
|
CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS J7516
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.71 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicaid |
$107.00
|
| Rate for Payer: AlohaCare Medicare |
$66.34
|
| Rate for Payer: AlohaCare Medicare |
$43.71
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Devoted Health Medicare |
$47.94
|
| Rate for Payer: Devoted Health Medicare |
$72.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$72.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$72.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$72.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$72.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$203.30
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$43.71
|
| Rate for Payer: Humana Medicare |
$66.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.34
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$128.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.34
|
| Rate for Payer: University Health Alliance Commercial |
$102.77
|
| Rate for Payer: University Health Alliance Commercial |
$155.98
|
|
|
CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION [9705]
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS J7516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.85 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.60
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
|
|
CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J7502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
CYCLOSPORINE MODIFIED 100 MG CAPSULE [28843]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J7502
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS J7502
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicare |
$139.50
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Devoted Health Medicare |
$153.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$139.50
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.50
|
| Rate for Payer: University Health Alliance Commercial |
$328.00
|
|
|
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION [28844]
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS J7502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
|
|
CYCLOSPORINE MODIFIED 25 MG CAPSULE [28842]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J7515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
