|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 70954013610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 64980056603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
DAPSONE 100 MG TABLET [2131]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 70954013610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
DAPTOMYCIN 500 MG/10ML IV (WET SOLR VIAL) [43036989]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
DAPTOMYCIN 500 MG/10ML IV (WET SOLR VIAL) [43036989]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$27.90
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$10.54
|
| Rate for Payer: Devoted Health Medicare |
$30.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Humana Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.90
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$27.90
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$30.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.90
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION [36989]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS J0878
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [173322]
|
Facility
|
IP
|
$19,030.00
|
|
|
Service Code
|
HCPCS J9144
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16,175.50 |
| Max. Negotiated Rate |
$18,459.10 |
| Rate for Payer: Cash Price |
$11,418.00
|
| Rate for Payer: Health Management Network Commercial |
$16,175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$17,127.00
|
| Rate for Payer: MDX Hawaii PPO |
$18,459.10
|
|
|
DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN [173322]
|
Facility
|
OP
|
$19,030.00
|
|
|
Service Code
|
HCPCS J9144
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$54.67 |
| Max. Negotiated Rate |
$18,459.10 |
| Rate for Payer: AlohaCare Medicaid |
$9,515.00
|
| Rate for Payer: AlohaCare Medicare |
$5,899.30
|
| Rate for Payer: Cash Price |
$11,418.00
|
| Rate for Payer: Cash Price |
$11,418.00
|
| Rate for Payer: Devoted Health Medicare |
$6,470.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$54.67
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$68.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,899.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$54.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18,078.50
|
| Rate for Payer: Health Management Network Commercial |
$16,175.50
|
| Rate for Payer: Humana Medicare |
$5,899.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$17,127.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,705.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,899.30
|
| Rate for Payer: MDX Hawaii PPO |
$18,459.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,899.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,899.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11,418.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,899.30
|
| Rate for Payer: University Health Alliance Commercial |
$13,870.97
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [129766]
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
HCPCS J0882
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$541.26 |
| Rate for Payer: AlohaCare Medicaid |
$279.00
|
| Rate for Payer: AlohaCare Medicare |
$172.98
|
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Devoted Health Medicare |
$189.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$3.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$530.10
|
| Rate for Payer: Health Management Network Commercial |
$474.30
|
| Rate for Payer: Humana Medicare |
$172.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$502.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$284.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.98
|
| Rate for Payer: MDX Hawaii PPO |
$541.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$334.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.98
|
| Rate for Payer: University Health Alliance Commercial |
$406.73
|
|
|
DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE [129766]
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
HCPCS J0882
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$474.30 |
| Max. Negotiated Rate |
$541.26 |
| Rate for Payer: Cash Price |
$334.80
|
| Rate for Payer: Health Management Network Commercial |
$474.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$502.20
|
| Rate for Payer: MDX Hawaii PPO |
$541.26
|
|
|
DAVOL BARD MESH PERFEX PLUG
|
Facility
|
OP
|
$1,067.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.77 |
| Max. Negotiated Rate |
$1,034.99 |
| Rate for Payer: AlohaCare Medicaid |
$533.50
|
| Rate for Payer: AlohaCare Medicare |
$330.77
|
| Rate for Payer: Cash Price |
$640.20
|
| Rate for Payer: Devoted Health Medicare |
$362.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$330.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$746.90
|
| Rate for Payer: Health Management Network Commercial |
$906.95
|
| Rate for Payer: Humana Medicare |
$330.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$960.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$544.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$330.77
|
| Rate for Payer: MDX Hawaii PPO |
$1,034.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$330.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$330.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$330.77
|
| Rate for Payer: University Health Alliance Commercial |
$597.52
|
|
|
DAVOL BARD MESH PERFEX PLUG
|
Facility
|
IP
|
$1,067.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$597.52 |
| Max. Negotiated Rate |
$1,034.99 |
| Rate for Payer: Cash Price |
$640.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$746.90
|
| Rate for Payer: Health Management Network Commercial |
$906.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$960.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,034.99
|
| Rate for Payer: University Health Alliance Commercial |
$597.52
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC
|
Facility
|
IP
|
$15,643.32
|
|
|
Service Code
|
MSDRG 744
|
| Min. Negotiated Rate |
$15,643.32 |
| Max. Negotiated Rate |
$15,643.32 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,643.32
|
|
|
D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC
|
Facility
|
IP
|
$15,643.32
|
|
|
Service Code
|
MSDRG 745
|
| Min. Negotiated Rate |
$15,643.32 |
| Max. Negotiated Rate |
$15,643.32 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,643.32
|
|
|
DCP PL 1.25 3X3H 04.503.712
|
Facility
|
IP
|
$2,235.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,251.60 |
| Max. Negotiated Rate |
$2,167.95 |
| Rate for Payer: Cash Price |
$1,341.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,564.50
|
| Rate for Payer: Health Management Network Commercial |
$1,899.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,011.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,167.95
|
| Rate for Payer: University Health Alliance Commercial |
$1,251.60
|
|
|
DCP PL 1.25 3X3H 04.503.712
|
Facility
|
OP
|
$2,235.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$692.85 |
| Max. Negotiated Rate |
$2,167.95 |
| Rate for Payer: AlohaCare Medicaid |
$1,117.50
|
| Rate for Payer: AlohaCare Medicare |
$692.85
|
| Rate for Payer: Cash Price |
$1,341.00
|
| Rate for Payer: Devoted Health Medicare |
$759.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$692.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,564.50
|
| Rate for Payer: Health Management Network Commercial |
$1,899.75
|
| Rate for Payer: Humana Medicare |
$692.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,011.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,139.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$692.85
|
| Rate for Payer: MDX Hawaii PPO |
$2,167.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$692.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$692.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$692.85
|
| Rate for Payer: University Health Alliance Commercial |
$1,251.60
|
|
|
DECELLULARIZED DERMIS AFLEX301
|
Facility
|
OP
|
$7,894.00
|
|
|
Service Code
|
HCPCS Q4125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.93 |
| Max. Negotiated Rate |
$7,657.18 |
| Rate for Payer: AlohaCare Medicaid |
$3,947.00
|
| Rate for Payer: AlohaCare Medicare |
$2,447.14
|
| Rate for Payer: Cash Price |
$4,736.40
|
| Rate for Payer: Cash Price |
$4,736.40
|
| Rate for Payer: Devoted Health Medicare |
$2,683.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$158.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,447.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,499.30
|
| Rate for Payer: Health Management Network Commercial |
$6,709.90
|
| Rate for Payer: Humana Medicare |
$2,447.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,104.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,025.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,447.14
|
| Rate for Payer: MDX Hawaii PPO |
$7,657.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,447.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,447.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,736.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,447.14
|
| Rate for Payer: University Health Alliance Commercial |
$5,753.94
|
|
|
DECELLULARIZED DERMIS AFLEX301
|
Facility
|
IP
|
$7,894.00
|
|
|
Service Code
|
HCPCS Q4125
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,709.90 |
| Max. Negotiated Rate |
$7,657.18 |
| Rate for Payer: Cash Price |
$4,736.40
|
| Rate for Payer: Health Management Network Commercial |
$6,709.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,104.60
|
| Rate for Payer: MDX Hawaii PPO |
$7,657.18
|
|
|
DECITABINE 50 MG/10ML IV (WET SOLR VIAL) [43076364]
|
Facility
|
IP
|
$2,451.00
|
|
|
Service Code
|
HCPCS J0894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,083.35 |
| Max. Negotiated Rate |
$2,377.47 |
| Rate for Payer: Cash Price |
$1,470.60
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Health Management Network Commercial |
$2,083.35
|
| Rate for Payer: Health Management Network Commercial |
$734.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,205.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$777.60
|
| Rate for Payer: MDX Hawaii PPO |
$838.08
|
| Rate for Payer: MDX Hawaii PPO |
$2,377.47
|
|
|
DECITABINE 50 MG/10ML IV (WET SOLR VIAL) [43076364]
|
Facility
|
OP
|
$2,451.00
|
|
|
Service Code
|
HCPCS J0894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2,377.47 |
| Rate for Payer: AlohaCare Medicaid |
$1,225.50
|
| Rate for Payer: AlohaCare Medicaid |
$432.00
|
| Rate for Payer: AlohaCare Medicare |
$267.84
|
| Rate for Payer: AlohaCare Medicare |
$759.81
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cash Price |
$1,470.60
|
| Rate for Payer: Cash Price |
$1,470.60
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Devoted Health Medicare |
$833.34
|
| Rate for Payer: Devoted Health Medicare |
$293.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$267.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$759.81
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,328.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$820.80
|
| Rate for Payer: Health Management Network Commercial |
$734.40
|
| Rate for Payer: Health Management Network Commercial |
$2,083.35
|
| Rate for Payer: Humana Medicare |
$759.81
|
| Rate for Payer: Humana Medicare |
$267.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,205.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$777.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$440.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,250.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$759.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$267.84
|
| Rate for Payer: MDX Hawaii PPO |
$2,377.47
|
| Rate for Payer: MDX Hawaii PPO |
$838.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$267.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$759.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$759.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$267.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$518.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,470.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$759.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$267.84
|
| Rate for Payer: University Health Alliance Commercial |
$1,786.53
|
| Rate for Payer: University Health Alliance Commercial |
$629.77
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
IP
|
$864.00
|
|
|
Service Code
|
HCPCS J0894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$734.40 |
| Max. Negotiated Rate |
$838.08 |
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cash Price |
$1,470.60
|
| Rate for Payer: Health Management Network Commercial |
$2,083.35
|
| Rate for Payer: Health Management Network Commercial |
$734.40
|
| Rate for Payer: Health Management Network Commercial |
$326.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$345.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$777.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,205.90
|
| Rate for Payer: MDX Hawaii PPO |
$372.48
|
| Rate for Payer: MDX Hawaii PPO |
$2,377.47
|
| Rate for Payer: MDX Hawaii PPO |
$838.08
|
|
|
DECITABINE 50 MG INTRAVENOUS SOLUTION [76364]
|
Facility
|
OP
|
$2,451.00
|
|
|
Service Code
|
HCPCS J0894
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2,377.47 |
| Rate for Payer: AlohaCare Medicaid |
$1,225.50
|
| Rate for Payer: AlohaCare Medicaid |
$432.00
|
| Rate for Payer: AlohaCare Medicaid |
$192.00
|
| Rate for Payer: AlohaCare Medicare |
$119.04
|
| Rate for Payer: AlohaCare Medicare |
$759.81
|
| Rate for Payer: AlohaCare Medicare |
$267.84
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cash Price |
$230.40
|
| Rate for Payer: Cash Price |
$1,470.60
|
| Rate for Payer: Cash Price |
$1,470.60
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Devoted Health Medicare |
$833.34
|
| Rate for Payer: Devoted Health Medicare |
$293.76
|
| Rate for Payer: Devoted Health Medicare |
$130.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$759.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$267.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$119.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$364.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,328.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$820.80
|
| Rate for Payer: Health Management Network Commercial |
$734.40
|
| Rate for Payer: Health Management Network Commercial |
$2,083.35
|
| Rate for Payer: Health Management Network Commercial |
$326.40
|
| Rate for Payer: Humana Medicare |
$759.81
|
| Rate for Payer: Humana Medicare |
$119.04
|
| Rate for Payer: Humana Medicare |
$267.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,205.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$345.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$777.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$440.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$195.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,250.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$759.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$119.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$267.84
|
| Rate for Payer: MDX Hawaii PPO |
$838.08
|
| Rate for Payer: MDX Hawaii PPO |
$372.48
|
| Rate for Payer: MDX Hawaii PPO |
$2,377.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$119.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$759.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$267.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$119.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$759.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$267.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$230.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,470.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$518.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$119.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$759.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$267.84
|
| Rate for Payer: University Health Alliance Commercial |
$1,786.53
|
| Rate for Payer: University Health Alliance Commercial |
$279.90
|
| Rate for Payer: University Health Alliance Commercial |
$629.77
|
|
|
DECOMPRESSION HIP 800-0541
|
Facility
|
OP
|
$4,464.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,383.84 |
| Max. Negotiated Rate |
$4,330.08 |
| Rate for Payer: AlohaCare Medicaid |
$2,232.00
|
| Rate for Payer: AlohaCare Medicare |
$1,383.84
|
| Rate for Payer: Cash Price |
$2,678.40
|
| Rate for Payer: Devoted Health Medicare |
$1,517.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,383.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,240.80
|
| Rate for Payer: Health Management Network Commercial |
$3,794.40
|
| Rate for Payer: Humana Medicare |
$1,383.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,017.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,276.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,383.84
|
| Rate for Payer: MDX Hawaii PPO |
$4,330.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,383.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,383.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,383.84
|
| Rate for Payer: University Health Alliance Commercial |
$3,253.81
|
|
|
DECOMPRESSION HIP 800-0541
|
Facility
|
IP
|
$4,464.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,794.40 |
| Max. Negotiated Rate |
$4,330.08 |
| Rate for Payer: Cash Price |
$2,678.40
|
| Rate for Payer: Health Management Network Commercial |
$3,794.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,017.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,330.08
|
|
