|
DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION [179013]
|
Facility
|
OP
|
$14,937.00
|
|
|
Service Code
|
HCPCS J9272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.82 |
| Max. Negotiated Rate |
$14,488.89 |
| Rate for Payer: AlohaCare Medicaid |
$7,468.50
|
| Rate for Payer: AlohaCare Medicare |
$4,630.47
|
| Rate for Payer: Cash Price |
$8,962.20
|
| Rate for Payer: Cash Price |
$8,962.20
|
| Rate for Payer: Devoted Health Medicare |
$5,078.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$243.82
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$308.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,630.47
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$243.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,190.15
|
| Rate for Payer: Health Management Network Commercial |
$12,696.45
|
| Rate for Payer: Humana Medicare |
$4,630.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,443.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,617.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,630.47
|
| Rate for Payer: MDX Hawaii PPO |
$14,488.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,630.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,630.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,962.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,630.47
|
| Rate for Payer: University Health Alliance Commercial |
$10,887.58
|
|
|
DOXEPIN 10 MG CAPSULE [2608]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079043601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DOXEPIN 10 MG CAPSULE [2608]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079043620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DOXEPIN 10 MG CAPSULE [2608]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079043601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DOXEPIN 10 MG CAPSULE [2608]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079043620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DOXEPIN 10 MG CAPSULE [2608]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 27241016701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DOXEPIN 10 MG CAPSULE [2608]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 27241016701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079043701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 27241016801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079043701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DOXEPIN 25 MG CAPSULE [2611]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 27241016801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DOXEPIN 50 MG CAPSULE [2612]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 27241016901
|
|
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
|
|
|
DOXEPIN 50 MG CAPSULE [2612]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 27241016901
|
|
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
|
|
|
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [204019]
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.55 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
|
|
DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION [204019]
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: AlohaCare Medicaid |
$21.50
|
| Rate for Payer: AlohaCare Medicare |
$13.33
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Devoted Health Medicare |
$14.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.85
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Humana Medicare |
$13.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.33
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.33
|
| Rate for Payer: University Health Alliance Commercial |
$31.34
|
|
|
DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION [204020]
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
|
|
DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION [204020]
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: AlohaCare Medicaid |
$30.50
|
| Rate for Payer: AlohaCare Medicare |
$18.91
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Devoted Health Medicare |
$20.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.95
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Humana Medicare |
$18.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.91
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.91
|
| Rate for Payer: University Health Alliance Commercial |
$44.46
|
|
|
DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [204018]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
|
DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION [204018]
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: AlohaCare Medicaid |
$37.00
|
| Rate for Payer: AlohaCare Medicare |
$22.94
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Devoted Health Medicare |
$25.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.94
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.30
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Humana Medicare |
$22.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.94
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.94
|
| Rate for Payer: University Health Alliance Commercial |
$53.94
|
|
|
DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]
|
Facility
|
IP
|
$474.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$402.90 |
| Max. Negotiated Rate |
$459.78 |
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Health Management Network Commercial |
$402.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$426.60
|
| Rate for Payer: MDX Hawaii PPO |
$459.78
|
|
|
DOXORUBICIN 50 MG INTRAVENOUS SOLUTION [2619]
|
Facility
|
OP
|
$474.00
|
|
|
Service Code
|
HCPCS J9000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$459.78 |
| Rate for Payer: AlohaCare Medicaid |
$237.00
|
| Rate for Payer: AlohaCare Medicare |
$146.94
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Cash Price |
$284.40
|
| Rate for Payer: Devoted Health Medicare |
$161.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$146.94
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$450.30
|
| Rate for Payer: Health Management Network Commercial |
$402.90
|
| Rate for Payer: Humana Medicare |
$146.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$426.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$241.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$146.94
|
| Rate for Payer: MDX Hawaii PPO |
$459.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$146.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$146.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$284.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$146.94
|
| Rate for Payer: University Health Alliance Commercial |
$345.50
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
OP
|
$4,042.00
|
|
|
Service Code
|
HCPCS Q2050
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.83 |
| Max. Negotiated Rate |
$3,920.74 |
| Rate for Payer: AlohaCare Medicaid |
$2,021.00
|
| Rate for Payer: AlohaCare Medicaid |
$480.50
|
| Rate for Payer: AlohaCare Medicaid |
$711.00
|
| Rate for Payer: AlohaCare Medicare |
$297.91
|
| Rate for Payer: AlohaCare Medicare |
$1,253.02
|
| Rate for Payer: AlohaCare Medicare |
$440.82
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cash Price |
$2,425.20
|
| Rate for Payer: Cash Price |
$2,425.20
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cash Price |
$576.60
|
| Rate for Payer: Cash Price |
$576.60
|
| Rate for Payer: Devoted Health Medicare |
$326.74
|
| Rate for Payer: Devoted Health Medicare |
$483.48
|
| Rate for Payer: Devoted Health Medicare |
$1,374.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$109.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$109.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$109.28
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$89.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$89.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$89.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$297.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$440.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,253.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$109.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$109.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$109.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,350.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$912.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,839.90
|
| Rate for Payer: Health Management Network Commercial |
$1,208.70
|
| Rate for Payer: Health Management Network Commercial |
$816.85
|
| Rate for Payer: Health Management Network Commercial |
$3,435.70
|
| Rate for Payer: Humana Medicare |
$297.91
|
| Rate for Payer: Humana Medicare |
$1,253.02
|
| Rate for Payer: Humana Medicare |
$440.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$864.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,637.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,279.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,061.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$725.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$490.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$440.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,253.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$297.91
|
| Rate for Payer: MDX Hawaii PPO |
$932.17
|
| Rate for Payer: MDX Hawaii PPO |
$1,379.34
|
| Rate for Payer: MDX Hawaii PPO |
$3,920.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$440.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,253.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$297.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$297.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,253.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$440.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$853.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,425.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$576.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,253.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$440.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$297.91
|
| Rate for Payer: University Health Alliance Commercial |
$2,946.21
|
| Rate for Payer: University Health Alliance Commercial |
$700.47
|
| Rate for Payer: University Health Alliance Commercial |
$1,036.50
|
|
|
DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION [27431]
|
Facility
|
IP
|
$961.00
|
|
|
Service Code
|
HCPCS Q2050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$816.85 |
| Max. Negotiated Rate |
$932.17 |
| Rate for Payer: Cash Price |
$576.60
|
| Rate for Payer: Cash Price |
$853.20
|
| Rate for Payer: Cash Price |
$2,425.20
|
| Rate for Payer: Health Management Network Commercial |
$816.85
|
| Rate for Payer: Health Management Network Commercial |
$3,435.70
|
| Rate for Payer: Health Management Network Commercial |
$1,208.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,279.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,637.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$864.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,920.74
|
| Rate for Payer: MDX Hawaii PPO |
$1,379.34
|
| Rate for Payer: MDX Hawaii PPO |
$932.17
|
|
|
DOXYCYCLINE 100 MG IN 100 ML NS ADD-A-VIAL (SIMPLE) [4080402]
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS J1271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.35 |
| Max. Negotiated Rate |
$88.27 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Health Management Network Commercial |
$77.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.90
|
| Rate for Payer: MDX Hawaii PPO |
$88.27
|
|
|
DOXYCYCLINE HYCLATE 100 MG/10ML IV (WET SOLR VIAL) [4302622]
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
NDC 63323013011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$671.50 |
| Max. Negotiated Rate |
$766.30 |
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Health Management Network Commercial |
$671.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.00
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
| Rate for Payer: MDX Hawaii PPO |
$766.30
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
|
