|
ENDURTY PULS GNRTR DDDR PM1260
|
Facility
|
OP
|
$11,200.00
|
|
|
Service Code
|
HCPCS C1786
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$3,472.00 |
| Max. Negotiated Rate |
$10,864.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,600.00
|
| Rate for Payer: AlohaCare Medicare |
$3,472.00
|
| Rate for Payer: Cash Price |
$6,720.00
|
| Rate for Payer: Devoted Health Medicare |
$3,808.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,472.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,840.00
|
| Rate for Payer: Health Management Network Commercial |
$9,520.00
|
| Rate for Payer: Humana Medicare |
$3,472.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,080.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,712.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,472.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,864.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,472.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,472.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,472.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,272.00
|
|
|
ENDURTY PULS GNRTR DDDR PM1260
|
Facility
|
IP
|
$11,200.00
|
|
|
Service Code
|
HCPCS C1786
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,272.00 |
| Max. Negotiated Rate |
$10,864.00 |
| Rate for Payer: Cash Price |
$6,720.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,840.00
|
| Rate for Payer: Health Management Network Commercial |
$9,520.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,080.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,864.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,272.00
|
|
|
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION [170496]
|
Facility
|
OP
|
$3,871.00
|
|
|
Service Code
|
HCPCS J9177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$3,754.87 |
| Rate for Payer: AlohaCare Medicaid |
$1,935.50
|
| Rate for Payer: AlohaCare Medicare |
$1,200.01
|
| Rate for Payer: Cash Price |
$2,322.60
|
| Rate for Payer: Cash Price |
$2,322.60
|
| Rate for Payer: Devoted Health Medicare |
$1,316.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,200.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,677.45
|
| Rate for Payer: Health Management Network Commercial |
$3,290.35
|
| Rate for Payer: Humana Medicare |
$1,200.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,483.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,974.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,200.01
|
| Rate for Payer: MDX Hawaii PPO |
$3,754.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,200.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,200.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,322.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,200.01
|
| Rate for Payer: University Health Alliance Commercial |
$2,821.57
|
|
|
ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION [170496]
|
Facility
|
IP
|
$3,871.00
|
|
|
Service Code
|
HCPCS J9177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,290.35 |
| Max. Negotiated Rate |
$3,754.87 |
| Rate for Payer: Cash Price |
$2,322.60
|
| Rate for Payer: Health Management Network Commercial |
$3,290.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,483.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,754.87
|
|
|
ENFORTUMAB VEDOTIN-EJFV 30 MG/3ML IV (WET SOLR VIAL) [430170497]
|
Facility
|
IP
|
$5,557.00
|
|
|
Service Code
|
HCPCS J9177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,723.45 |
| Max. Negotiated Rate |
$5,390.29 |
| Rate for Payer: Cash Price |
$3,334.20
|
| Rate for Payer: Health Management Network Commercial |
$4,723.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,001.30
|
| Rate for Payer: MDX Hawaii PPO |
$5,390.29
|
|
|
ENFORTUMAB VEDOTIN-EJFV 30 MG/3ML IV (WET SOLR VIAL) [430170497]
|
Facility
|
OP
|
$5,557.00
|
|
|
Service Code
|
HCPCS J9177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$5,390.29 |
| Rate for Payer: AlohaCare Medicaid |
$2,778.50
|
| Rate for Payer: AlohaCare Medicare |
$1,722.67
|
| Rate for Payer: Cash Price |
$3,334.20
|
| Rate for Payer: Cash Price |
$3,334.20
|
| Rate for Payer: Devoted Health Medicare |
$1,889.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,722.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,279.15
|
| Rate for Payer: Health Management Network Commercial |
$4,723.45
|
| Rate for Payer: Humana Medicare |
$1,722.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,001.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,834.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,722.67
|
| Rate for Payer: MDX Hawaii PPO |
$5,390.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,722.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,722.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,334.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,722.67
|
| Rate for Payer: University Health Alliance Commercial |
$4,050.50
|
|
|
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION [170497]
|
Facility
|
OP
|
$4,124.00
|
|
|
Service Code
|
HCPCS J9177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.66 |
| Max. Negotiated Rate |
$4,000.28 |
| Rate for Payer: AlohaCare Medicaid |
$2,062.00
|
| Rate for Payer: AlohaCare Medicaid |
$2,778.50
|
| Rate for Payer: AlohaCare Medicare |
$1,722.67
|
| Rate for Payer: AlohaCare Medicare |
$1,278.44
|
| Rate for Payer: Cash Price |
$3,334.20
|
| Rate for Payer: Cash Price |
$2,474.40
|
| Rate for Payer: Cash Price |
$3,334.20
|
| Rate for Payer: Cash Price |
$2,474.40
|
| Rate for Payer: Devoted Health Medicare |
$1,402.16
|
| Rate for Payer: Devoted Health Medicare |
$1,889.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$45.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,722.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,278.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$36.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,917.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,279.15
|
| Rate for Payer: Health Management Network Commercial |
$4,723.45
|
| Rate for Payer: Health Management Network Commercial |
$3,505.40
|
| Rate for Payer: Humana Medicare |
$1,278.44
|
| Rate for Payer: Humana Medicare |
$1,722.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,711.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,001.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,834.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,103.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,278.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,722.67
|
| Rate for Payer: MDX Hawaii PPO |
$4,000.28
|
| Rate for Payer: MDX Hawaii PPO |
$5,390.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,722.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,278.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,278.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,722.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,334.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,474.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,278.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,722.67
|
| Rate for Payer: University Health Alliance Commercial |
$3,005.98
|
| Rate for Payer: University Health Alliance Commercial |
$4,050.50
|
|
|
ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION [170497]
|
Facility
|
IP
|
$4,124.00
|
|
|
Service Code
|
HCPCS J9177
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,505.40 |
| Max. Negotiated Rate |
$4,000.28 |
| Rate for Payer: Cash Price |
$2,474.40
|
| Rate for Payer: Cash Price |
$3,334.20
|
| Rate for Payer: Health Management Network Commercial |
$3,505.40
|
| Rate for Payer: Health Management Network Commercial |
$4,723.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,711.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,001.30
|
| Rate for Payer: MDX Hawaii PPO |
$5,390.29
|
| Rate for Payer: MDX Hawaii PPO |
$4,000.28
|
|
|
ENOVIS SR MCP IMPLANT SIZE LG
|
Facility
|
IP
|
$7,650.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,284.00 |
| Max. Negotiated Rate |
$7,420.50 |
| Rate for Payer: Cash Price |
$4,590.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,355.00
|
| Rate for Payer: Health Management Network Commercial |
$6,502.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,885.00
|
| Rate for Payer: MDX Hawaii PPO |
$7,420.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,284.00
|
|
|
ENOVIS SR MCP IMPLANT SIZE LG
|
Facility
|
OP
|
$7,650.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,371.50 |
| Max. Negotiated Rate |
$7,420.50 |
| Rate for Payer: AlohaCare Medicaid |
$3,825.00
|
| Rate for Payer: AlohaCare Medicare |
$2,371.50
|
| Rate for Payer: Cash Price |
$4,590.00
|
| Rate for Payer: Devoted Health Medicare |
$2,601.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,371.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,355.00
|
| Rate for Payer: Health Management Network Commercial |
$6,502.50
|
| Rate for Payer: Humana Medicare |
$2,371.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,885.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,901.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,371.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,420.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,371.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,371.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,371.50
|
| Rate for Payer: University Health Alliance Commercial |
$4,284.00
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [183776]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE [183776]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [183777]
|
Facility
|
OP
|
$34.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: AlohaCare Medicaid |
$17.00
|
| Rate for Payer: AlohaCare Medicare |
$10.54
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Devoted Health Medicare |
$11.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.54
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$32.30
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Humana Medicare |
$10.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.54
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.54
|
| Rate for Payer: University Health Alliance Commercial |
$24.78
|
|
|
ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE [183777]
|
Facility
|
IP
|
$34.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.90 |
| Max. Negotiated Rate |
$32.98 |
| Rate for Payer: Cash Price |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$28.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$32.98
|
|
|
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [183778]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE [183778]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$13.02
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$13.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.02
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [183772]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE [183772]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [183773]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE [183773]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [183774]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| 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 |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| 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
|
|
|
ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE [183774]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J1650
|
|
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
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [183775]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
|
|
ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE [183775]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J1650
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicare |
$7.13
|
| Rate for Payer: AlohaCare Medicare |
$14.88
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Devoted Health Medicare |
$7.82
|
| Rate for Payer: Devoted Health Medicare |
$16.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.60
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Humana Medicare |
$7.13
|
| Rate for Payer: Humana Medicare |
$14.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.88
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.13
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
| Rate for Payer: University Health Alliance Commercial |
$34.99
|
|
|
ENROUTE RX BALLOON SR-5025-BC
|
Facility
|
OP
|
$1,397.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$433.07 |
| Max. Negotiated Rate |
$1,355.09 |
| Rate for Payer: AlohaCare Medicaid |
$698.50
|
| Rate for Payer: AlohaCare Medicare |
$433.07
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Devoted Health Medicare |
$474.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$433.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,327.15
|
| Rate for Payer: Health Management Network Commercial |
$1,187.45
|
| Rate for Payer: Humana Medicare |
$433.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,257.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$712.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$433.07
|
| Rate for Payer: MDX Hawaii PPO |
$1,355.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$433.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$433.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$433.07
|
| Rate for Payer: University Health Alliance Commercial |
$1,018.27
|
|
