|
LEUCOVORIN CALCIUM 100 MG/10ML IJ (WET SOLR VIAL) [4304392]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
|
|
LEUCOVORIN CALCIUM 100 MG/10ML IJ (WET SOLR VIAL) [4304392]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$14.88
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$16.32
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Humana Medicare |
$14.88
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$34.99
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: AlohaCare Medicaid |
$24.00
|
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$14.88
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$16.32
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Humana Medicare |
$14.88
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$34.99
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION [4392]
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.80 |
| Max. Negotiated Rate |
$46.56 |
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$46.56
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$61.20
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: MDX Hawaii PPO |
$69.84
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicaid |
$36.00
|
| Rate for Payer: AlohaCare Medicaid |
$35.00
|
| Rate for Payer: AlohaCare Medicare |
$21.70
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: AlohaCare Medicare |
$22.32
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Devoted Health Medicare |
$24.48
|
| Rate for Payer: Devoted Health Medicare |
$23.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$61.20
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Humana Medicare |
$21.70
|
| Rate for Payer: Humana Medicare |
$22.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.32
|
| Rate for Payer: MDX Hawaii PPO |
$69.84
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$36.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.32
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
| Rate for Payer: University Health Alliance Commercial |
$51.02
|
| Rate for Payer: University Health Alliance Commercial |
$52.48
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
OP
|
$168.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicaid |
$39.00
|
| Rate for Payer: AlohaCare Medicare |
$24.18
|
| Rate for Payer: AlohaCare Medicare |
$52.08
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Devoted Health Medicare |
$57.12
|
| Rate for Payer: Devoted Health Medicare |
$26.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.10
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Humana Medicare |
$52.08
|
| Rate for Payer: Humana Medicare |
$24.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.18
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.18
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
| Rate for Payer: University Health Alliance Commercial |
$56.85
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]
|
Facility
|
IP
|
$168.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.80 |
| Max. Negotiated Rate |
$162.96 |
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: AlohaCare Medicaid |
$78.00
|
| Rate for Payer: AlohaCare Medicaid |
$79.50
|
| Rate for Payer: AlohaCare Medicare |
$49.29
|
| Rate for Payer: AlohaCare Medicare |
$48.36
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Devoted Health Medicare |
$53.04
|
| Rate for Payer: Devoted Health Medicare |
$54.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$151.05
|
| Rate for Payer: Health Management Network Commercial |
$135.15
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Humana Medicare |
$48.36
|
| Rate for Payer: Humana Medicare |
$49.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$143.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.29
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
| Rate for Payer: MDX Hawaii PPO |
$154.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$95.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.29
|
| Rate for Payer: University Health Alliance Commercial |
$113.71
|
| Rate for Payer: University Health Alliance Commercial |
$115.90
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Health Management Network Commercial |
$135.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$143.10
|
| Rate for Payer: MDX Hawaii PPO |
$154.23
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0640
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$9.30
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$10.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$9.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.30
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.30
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
|
IP
|
$2,662.00
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,262.70 |
| Max. Negotiated Rate |
$2,582.14 |
| Rate for Payer: Cash Price |
$1,597.20
|
| Rate for Payer: Health Management Network Commercial |
$2,262.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,395.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,582.14
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT [13691]
|
Facility
|
OP
|
$2,662.00
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$825.22 |
| Max. Negotiated Rate |
$2,582.14 |
| Rate for Payer: AlohaCare Medicaid |
$1,331.00
|
| Rate for Payer: AlohaCare Medicare |
$825.22
|
| Rate for Payer: Cash Price |
$1,597.20
|
| Rate for Payer: Cash Price |
$1,597.20
|
| Rate for Payer: Devoted Health Medicare |
$905.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,737.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,206.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$825.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,737.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,528.90
|
| Rate for Payer: Health Management Network Commercial |
$2,262.70
|
| Rate for Payer: Humana Medicare |
$825.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,395.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,357.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.22
|
| Rate for Payer: MDX Hawaii PPO |
$2,582.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$825.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$825.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,597.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$825.22
|
| Rate for Payer: University Health Alliance Commercial |
$1,940.33
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
OP
|
$814.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$789.58 |
| Rate for Payer: AlohaCare Medicaid |
$407.00
|
| Rate for Payer: AlohaCare Medicare |
$252.34
|
| Rate for Payer: Cash Price |
$488.40
|
| Rate for Payer: Cash Price |
$488.40
|
| Rate for Payer: Devoted Health Medicare |
$276.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$252.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$773.30
|
| Rate for Payer: Health Management Network Commercial |
$691.90
|
| Rate for Payer: Humana Medicare |
$252.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$732.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$415.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$252.34
|
| Rate for Payer: MDX Hawaii PPO |
$789.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$252.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$252.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$488.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$252.34
|
| Rate for Payer: University Health Alliance Commercial |
$593.32
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE [32893]
|
Facility
|
IP
|
$814.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$691.90 |
| Max. Negotiated Rate |
$789.58 |
| Rate for Payer: Cash Price |
$488.40
|
| Rate for Payer: Health Management Network Commercial |
$691.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$732.60
|
| Rate for Payer: MDX Hawaii PPO |
$789.58
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
IP
|
$6,985.00
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,937.25 |
| Max. Negotiated Rate |
$6,775.45 |
| Rate for Payer: Cash Price |
$4,191.00
|
| Rate for Payer: Health Management Network Commercial |
$5,937.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,286.50
|
| Rate for Payer: MDX Hawaii PPO |
$6,775.45
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
OP
|
$6,985.00
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,737.10 |
| Max. Negotiated Rate |
$6,775.45 |
| Rate for Payer: AlohaCare Medicaid |
$3,492.50
|
| Rate for Payer: AlohaCare Medicare |
$2,165.35
|
| Rate for Payer: Cash Price |
$4,191.00
|
| Rate for Payer: Cash Price |
$4,191.00
|
| Rate for Payer: Devoted Health Medicare |
$2,374.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,737.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,206.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,165.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,737.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,635.75
|
| Rate for Payer: Health Management Network Commercial |
$5,937.25
|
| Rate for Payer: Humana Medicare |
$2,165.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,286.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,562.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,165.35
|
| Rate for Payer: MDX Hawaii PPO |
$6,775.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,165.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,165.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,191.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,165.35
|
| Rate for Payer: University Health Alliance Commercial |
$5,091.37
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
OP
|
$8,227.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$7,980.19 |
| Rate for Payer: AlohaCare Medicaid |
$4,113.50
|
| Rate for Payer: AlohaCare Medicare |
$2,550.37
|
| Rate for Payer: Cash Price |
$4,936.20
|
| Rate for Payer: Cash Price |
$4,936.20
|
| Rate for Payer: Devoted Health Medicare |
$2,797.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,550.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,815.65
|
| Rate for Payer: Health Management Network Commercial |
$6,992.95
|
| Rate for Payer: Humana Medicare |
$2,550.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,404.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,195.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,550.37
|
| Rate for Payer: MDX Hawaii PPO |
$7,980.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,550.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,550.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,936.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,550.37
|
| Rate for Payer: University Health Alliance Commercial |
$5,996.66
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
IP
|
$8,227.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,992.95 |
| Max. Negotiated Rate |
$7,980.19 |
| Rate for Payer: Cash Price |
$4,936.20
|
| Rate for Payer: Health Management Network Commercial |
$6,992.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,404.30
|
| Rate for Payer: MDX Hawaii PPO |
$7,980.19
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
OP
|
$2,127.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$2,063.19 |
| Rate for Payer: AlohaCare Medicaid |
$1,063.50
|
| Rate for Payer: AlohaCare Medicare |
$659.37
|
| Rate for Payer: Cash Price |
$1,276.20
|
| Rate for Payer: Cash Price |
$1,276.20
|
| Rate for Payer: Devoted Health Medicare |
$723.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$659.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,020.65
|
| Rate for Payer: Health Management Network Commercial |
$1,807.95
|
| Rate for Payer: Humana Medicare |
$659.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,914.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,084.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$659.37
|
| Rate for Payer: MDX Hawaii PPO |
$2,063.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$659.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$659.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,276.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$659.37
|
| Rate for Payer: University Health Alliance Commercial |
$1,550.37
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
IP
|
$2,127.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,807.95 |
| Max. Negotiated Rate |
$2,063.19 |
| Rate for Payer: Cash Price |
$1,276.20
|
| Rate for Payer: Health Management Network Commercial |
$1,807.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,914.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,063.19
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [40801]
|
Facility
|
IP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,190.05 |
| Max. Negotiated Rate |
$3,640.41 |
| Rate for Payer: Cash Price |
$2,251.80
|
| Rate for Payer: Health Management Network Commercial |
$3,190.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,377.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,640.41
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [40801]
|
Facility
|
OP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$3,640.41 |
| Rate for Payer: AlohaCare Medicaid |
$1,876.50
|
| Rate for Payer: AlohaCare Medicare |
$1,163.43
|
| Rate for Payer: Cash Price |
$2,251.80
|
| Rate for Payer: Cash Price |
$2,251.80
|
| Rate for Payer: Devoted Health Medicare |
$1,276.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,163.43
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,565.35
|
| Rate for Payer: Health Management Network Commercial |
$3,190.05
|
| Rate for Payer: Humana Medicare |
$1,163.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,377.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,914.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,163.43
|
| Rate for Payer: MDX Hawaii PPO |
$3,640.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,163.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,163.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,251.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,163.43
|
| Rate for Payer: University Health Alliance Commercial |
$2,735.56
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [110751]
|
Facility
|
OP
|
$15,954.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$15,475.38 |
| Rate for Payer: AlohaCare Medicaid |
$7,977.00
|
| Rate for Payer: AlohaCare Medicare |
$4,945.74
|
| Rate for Payer: Cash Price |
$9,572.40
|
| Rate for Payer: Cash Price |
$9,572.40
|
| Rate for Payer: Devoted Health Medicare |
$5,424.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,945.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,156.30
|
| Rate for Payer: Health Management Network Commercial |
$13,560.90
|
| Rate for Payer: Humana Medicare |
$4,945.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,358.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,136.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,945.74
|
| Rate for Payer: MDX Hawaii PPO |
$15,475.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,945.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,945.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,572.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,945.74
|
| Rate for Payer: University Health Alliance Commercial |
$11,628.87
|
|
