|
LOSARTAN 50 MG TABLET [14824]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68084034711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
LOSARTAN TABLETS (COZAAR) 25 MG (TAKE HOME) [4080371]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080159
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
LOSARTAN TABLETS (COZAAR) 25 MG (TAKE HOME) [4080371]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080159
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC
|
Facility
|
IP
|
$54,751.62
|
|
|
Service Code
|
MSDRG 493
|
| Min. Negotiated Rate |
$54,751.62 |
| Max. Negotiated Rate |
$54,751.62 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$54,751.62
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC
|
Facility
|
IP
|
$54,751.62
|
|
|
Service Code
|
MSDRG 492
|
| Min. Negotiated Rate |
$54,751.62 |
| Max. Negotiated Rate |
$54,751.62 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$54,751.62
|
|
|
LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC
|
Facility
|
IP
|
$32,329.53
|
|
|
Service Code
|
MSDRG 494
|
| Min. Negotiated Rate |
$32,329.53 |
| Max. Negotiated Rate |
$32,329.53 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,329.53
|
|
|
LOW INTENSITY HEPARIN CALCULATOR BOLUS [4080207]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
LOW INTENSITY HEPARIN CALCULATOR BOLUS [4080207]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J1644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicaid |
$15.50
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$9.61
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$10.54
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Humana Medicare |
$9.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.61
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
LUNG TRANSPLANT
|
Facility
|
IP
|
$10,400.00
|
|
|
Service Code
|
MSDRG 007
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$10,400.00 |
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
LURASIDONE 20 MG TABLET [113587]
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
NDC 62332049430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.45 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: AlohaCare Medicaid |
$47.50
|
| Rate for Payer: AlohaCare Medicare |
$29.45
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Devoted Health Medicare |
$32.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.25
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Humana Medicare |
$29.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.45
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.45
|
| Rate for Payer: University Health Alliance Commercial |
$69.25
|
|
|
LURASIDONE 20 MG TABLET [113587]
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
NDC 62332049430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
NDC 62332049530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
NDC 62332049530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.45 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: AlohaCare Medicaid |
$47.50
|
| Rate for Payer: AlohaCare Medicare |
$29.45
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Devoted Health Medicare |
$32.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.25
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Humana Medicare |
$29.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.45
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.45
|
| Rate for Payer: University Health Alliance Commercial |
$69.25
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
NDC 47335068483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.55 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
|
|
LURASIDONE 40 MG TABLET [107668]
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
NDC 47335068483
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.93 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: AlohaCare Medicaid |
$51.50
|
| Rate for Payer: AlohaCare Medicare |
$31.93
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Devoted Health Medicare |
$35.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.85
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Humana Medicare |
$31.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.93
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.93
|
| Rate for Payer: University Health Alliance Commercial |
$75.08
|
|
|
LURBINECTEDIN 4 MG/8 ML IV (WET SOLR VIAL) [430173604]
|
Facility
|
IP
|
$10,400.00
|
|
|
Service Code
|
HCPCS J9223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,840.00 |
| Max. Negotiated Rate |
$10,088.00 |
| Rate for Payer: Cash Price |
$6,240.00
|
| Rate for Payer: Health Management Network Commercial |
$8,840.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,088.00
|
|
|
LURBINECTEDIN 4 MG/8 ML IV (WET SOLR VIAL) [430173604]
|
Facility
|
OP
|
$10,400.00
|
|
|
Service Code
|
HCPCS J9223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.13 |
| Max. Negotiated Rate |
$10,088.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,200.00
|
| Rate for Payer: AlohaCare Medicare |
$3,224.00
|
| Rate for Payer: Cash Price |
$6,240.00
|
| Rate for Payer: Cash Price |
$6,240.00
|
| Rate for Payer: Devoted Health Medicare |
$3,536.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$206.13
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$265.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,224.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$206.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,880.00
|
| Rate for Payer: Health Management Network Commercial |
$8,840.00
|
| Rate for Payer: Humana Medicare |
$3,224.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,360.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,304.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,224.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,088.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,224.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,224.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,240.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,224.00
|
| Rate for Payer: University Health Alliance Commercial |
$7,580.56
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [173604]
|
Facility
|
OP
|
$10,400.00
|
|
|
Service Code
|
HCPCS J9223
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$206.13 |
| Max. Negotiated Rate |
$10,088.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,200.00
|
| Rate for Payer: AlohaCare Medicaid |
$6,111.00
|
| Rate for Payer: AlohaCare Medicare |
$3,788.82
|
| Rate for Payer: AlohaCare Medicare |
$3,224.00
|
| Rate for Payer: Cash Price |
$7,333.20
|
| Rate for Payer: Cash Price |
$6,240.00
|
| Rate for Payer: Cash Price |
$7,333.20
|
| Rate for Payer: Cash Price |
$6,240.00
|
| Rate for Payer: Devoted Health Medicare |
$3,536.00
|
| Rate for Payer: Devoted Health Medicare |
$4,155.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$206.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$206.13
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$265.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$265.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,788.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,224.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$206.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$206.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,880.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,610.90
|
| Rate for Payer: Health Management Network Commercial |
$10,388.70
|
| Rate for Payer: Health Management Network Commercial |
$8,840.00
|
| Rate for Payer: Humana Medicare |
$3,224.00
|
| Rate for Payer: Humana Medicare |
$3,788.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,999.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,233.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,304.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,224.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,788.82
|
| Rate for Payer: MDX Hawaii PPO |
$10,088.00
|
| Rate for Payer: MDX Hawaii PPO |
$11,855.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,788.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,224.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,224.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,788.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,333.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,240.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,224.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,788.82
|
| Rate for Payer: University Health Alliance Commercial |
$7,580.56
|
| Rate for Payer: University Health Alliance Commercial |
$8,908.62
|
|
|
LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION [173604]
|
Facility
|
IP
|
$10,400.00
|
|
|
Service Code
|
HCPCS J9223
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8,840.00 |
| Max. Negotiated Rate |
$10,088.00 |
| Rate for Payer: Cash Price |
$6,240.00
|
| Rate for Payer: Cash Price |
$7,333.20
|
| Rate for Payer: Health Management Network Commercial |
$8,840.00
|
| Rate for Payer: Health Management Network Commercial |
$10,388.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,999.80
|
| Rate for Payer: MDX Hawaii PPO |
$11,855.34
|
| Rate for Payer: MDX Hawaii PPO |
$10,088.00
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [170335]
|
Facility
|
OP
|
$5,436.00
|
|
|
Service Code
|
HCPCS J0896
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$5,272.92 |
| Rate for Payer: AlohaCare Medicaid |
$2,718.00
|
| Rate for Payer: AlohaCare Medicare |
$1,685.16
|
| Rate for Payer: Cash Price |
$3,261.60
|
| Rate for Payer: Cash Price |
$3,261.60
|
| Rate for Payer: Devoted Health Medicare |
$1,848.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$41.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$53.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,685.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$41.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,164.20
|
| Rate for Payer: Health Management Network Commercial |
$4,620.60
|
| Rate for Payer: Humana Medicare |
$1,685.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,892.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,772.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,685.16
|
| Rate for Payer: MDX Hawaii PPO |
$5,272.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,685.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,685.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,261.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,685.16
|
| Rate for Payer: University Health Alliance Commercial |
$3,962.30
|
|
|
LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION [170335]
|
Facility
|
IP
|
$5,436.00
|
|
|
Service Code
|
HCPCS J0896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,620.60 |
| Max. Negotiated Rate |
$5,272.92 |
| Rate for Payer: Cash Price |
$3,261.60
|
| Rate for Payer: Health Management Network Commercial |
$4,620.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,892.40
|
| Rate for Payer: MDX Hawaii PPO |
$5,272.92
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [170336]
|
Facility
|
OP
|
$15,308.00
|
|
|
Service Code
|
HCPCS J0896
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.96 |
| Max. Negotiated Rate |
$14,848.76 |
| Rate for Payer: AlohaCare Medicaid |
$7,654.00
|
| Rate for Payer: AlohaCare Medicare |
$4,745.48
|
| Rate for Payer: Cash Price |
$9,184.80
|
| Rate for Payer: Cash Price |
$9,184.80
|
| Rate for Payer: Devoted Health Medicare |
$5,204.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$41.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$53.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,745.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$41.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,542.60
|
| Rate for Payer: Health Management Network Commercial |
$13,011.80
|
| Rate for Payer: Humana Medicare |
$4,745.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,777.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,807.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,745.48
|
| Rate for Payer: MDX Hawaii PPO |
$14,848.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,745.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,745.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,184.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,745.48
|
| Rate for Payer: University Health Alliance Commercial |
$11,158.00
|
|
|
LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION [170336]
|
Facility
|
IP
|
$15,308.00
|
|
|
Service Code
|
HCPCS J0896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,011.80 |
| Max. Negotiated Rate |
$14,848.76 |
| Rate for Payer: Cash Price |
$9,184.80
|
| Rate for Payer: Health Management Network Commercial |
$13,011.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,777.20
|
| Rate for Payer: MDX Hawaii PPO |
$14,848.76
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [151258]
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
NDC 69488000301
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$96.10 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$96.10
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Devoted Health Medicare |
$105.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$96.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$294.50
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$96.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.10
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$96.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$96.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$96.10
|
| Rate for Payer: University Health Alliance Commercial |
$225.96
|
|
|
LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION [151258]
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
NDC 69488000301
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$263.50 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
|
