|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 68084012001
|
|
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
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 13107000334
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 68084012001
|
|
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
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 13107000334
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
MIRTAZAPINE 30 MG TABLET [17465]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 68084012011
|
|
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
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [188970]
|
Facility
|
OP
|
$12,209.00
|
|
|
Service Code
|
HCPCS J9063
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.52 |
| Max. Negotiated Rate |
$11,842.73 |
| Rate for Payer: AlohaCare Medicaid |
$6,104.50
|
| Rate for Payer: AlohaCare Medicaid |
$15,749.00
|
| Rate for Payer: AlohaCare Medicare |
$9,764.38
|
| Rate for Payer: AlohaCare Medicare |
$3,784.79
|
| Rate for Payer: Cash Price |
$18,898.80
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$18,898.80
|
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Devoted Health Medicare |
$4,151.06
|
| Rate for Payer: Devoted Health Medicare |
$10,709.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$69.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$69.52
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$88.91
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$88.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,764.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,784.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$69.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$69.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,598.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29,923.10
|
| Rate for Payer: Health Management Network Commercial |
$26,773.30
|
| Rate for Payer: Health Management Network Commercial |
$10,377.65
|
| Rate for Payer: Humana Medicare |
$3,784.79
|
| Rate for Payer: Humana Medicare |
$9,764.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,988.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$28,348.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16,063.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,226.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,784.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,764.38
|
| Rate for Payer: MDX Hawaii PPO |
$11,842.73
|
| Rate for Payer: MDX Hawaii PPO |
$30,553.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,764.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,784.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,784.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,764.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18,898.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,325.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,784.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,764.38
|
| Rate for Payer: University Health Alliance Commercial |
$8,899.14
|
| Rate for Payer: University Health Alliance Commercial |
$22,958.89
|
|
|
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML INTRAVENOUS SOLUTION [188970]
|
Facility
|
IP
|
$12,209.00
|
|
|
Service Code
|
HCPCS J9063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10,377.65 |
| Max. Negotiated Rate |
$11,842.73 |
| Rate for Payer: Cash Price |
$7,325.40
|
| Rate for Payer: Cash Price |
$18,898.80
|
| Rate for Payer: Health Management Network Commercial |
$10,377.65
|
| Rate for Payer: Health Management Network Commercial |
$26,773.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,988.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$28,348.20
|
| Rate for Payer: MDX Hawaii PPO |
$30,553.06
|
| Rate for Payer: MDX Hawaii PPO |
$11,842.73
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC
|
Facility
|
IP
|
$20,217.81
|
|
|
Service Code
|
MSDRG 640
|
| Min. Negotiated Rate |
$20,217.81 |
| Max. Negotiated Rate |
$20,217.81 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20,217.81
|
|
|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$15,738.13
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$15,738.13 |
| Max. Negotiated Rate |
$15,738.13 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,738.13
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 59762500701
|
|
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
|
|
|
MISOPROSTOL 100 MCG TABLET [10628]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 59762500701
|
|
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
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 60687074601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 60687074611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 60687074611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
MISOPROSTOL 200 MCG TABLET [10629]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 60687074601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
MISOPROSTOL 25 MCG QUARTER TABLET [400620]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 09999701554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
MISOPROSTOL 25 MCG QUARTER TABLET [400620]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 09999701554
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
OP
|
$2,276.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$2,207.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,138.00
|
| Rate for Payer: AlohaCare Medicaid |
$405.00
|
| Rate for Payer: AlohaCare Medicaid |
$569.00
|
| Rate for Payer: AlohaCare Medicare |
$251.10
|
| Rate for Payer: AlohaCare Medicare |
$705.56
|
| Rate for Payer: AlohaCare Medicare |
$352.78
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$1,365.60
|
| Rate for Payer: Cash Price |
$1,365.60
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Devoted Health Medicare |
$275.40
|
| Rate for Payer: Devoted Health Medicare |
$386.92
|
| Rate for Payer: Devoted Health Medicare |
$773.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$251.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$352.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$705.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,081.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$769.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,162.20
|
| Rate for Payer: Health Management Network Commercial |
$967.30
|
| Rate for Payer: Health Management Network Commercial |
$688.50
|
| Rate for Payer: Health Management Network Commercial |
$1,934.60
|
| Rate for Payer: Humana Medicare |
$251.10
|
| Rate for Payer: Humana Medicare |
$705.56
|
| Rate for Payer: Humana Medicare |
$352.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$729.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,048.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,024.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,160.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$580.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$413.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$352.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$705.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$251.10
|
| Rate for Payer: MDX Hawaii PPO |
$785.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,103.86
|
| Rate for Payer: MDX Hawaii PPO |
$2,207.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$352.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$705.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$251.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$251.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$705.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$352.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$682.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,365.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$486.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$705.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$352.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$251.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,658.98
|
| Rate for Payer: University Health Alliance Commercial |
$590.41
|
| Rate for Payer: University Health Alliance Commercial |
$829.49
|
|
|
MITOMYCIN 20 MG INTRAVENOUS SOLUTION [10630]
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$688.50 |
| Max. Negotiated Rate |
$785.70 |
| Rate for Payer: Cash Price |
$486.00
|
| Rate for Payer: Cash Price |
$682.80
|
| Rate for Payer: Cash Price |
$1,365.60
|
| Rate for Payer: Health Management Network Commercial |
$688.50
|
| Rate for Payer: Health Management Network Commercial |
$1,934.60
|
| Rate for Payer: Health Management Network Commercial |
$967.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,024.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,048.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$729.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,207.72
|
| Rate for Payer: MDX Hawaii PPO |
$1,103.86
|
| Rate for Payer: MDX Hawaii PPO |
$785.70
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,445.00 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cash Price |
$1,210.20
|
| Rate for Payer: Health Management Network Commercial |
$1,445.00
|
| Rate for Payer: Health Management Network Commercial |
$1,714.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,530.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,815.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,956.49
|
| Rate for Payer: MDX Hawaii PPO |
$1,649.00
|
|
|
MITOMYCIN 40 MG INTRAVENOUS SOLUTION [10631]
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS J9280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$1,649.00 |
| Rate for Payer: AlohaCare Medicaid |
$850.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,008.50
|
| Rate for Payer: AlohaCare Medicare |
$625.27
|
| Rate for Payer: AlohaCare Medicare |
$527.00
|
| Rate for Payer: Cash Price |
$1,210.20
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Cash Price |
$1,210.20
|
| Rate for Payer: Cash Price |
$1,020.00
|
| Rate for Payer: Devoted Health Medicare |
$578.00
|
| Rate for Payer: Devoted Health Medicare |
$685.78
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$35.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$625.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$527.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,615.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,916.15
|
| Rate for Payer: Health Management Network Commercial |
$1,714.45
|
| Rate for Payer: Health Management Network Commercial |
$1,445.00
|
| Rate for Payer: Humana Medicare |
$527.00
|
| Rate for Payer: Humana Medicare |
$625.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,530.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,815.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,028.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$867.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$527.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$625.27
|
| Rate for Payer: MDX Hawaii PPO |
$1,649.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,956.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$625.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$527.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$527.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$625.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,210.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,020.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$527.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$625.27
|
| Rate for Payer: University Health Alliance Commercial |
$1,239.13
|
| Rate for Payer: University Health Alliance Commercial |
$1,470.19
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL COMPOUNDED [4080435]
|
Facility
|
OP
|
$25,845.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.42 |
| Max. Negotiated Rate |
$25,069.65 |
| Rate for Payer: AlohaCare Medicaid |
$12,922.50
|
| Rate for Payer: AlohaCare Medicare |
$8,011.95
|
| Rate for Payer: Cash Price |
$15,507.00
|
| Rate for Payer: Cash Price |
$15,507.00
|
| Rate for Payer: Devoted Health Medicare |
$8,787.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$317.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$403.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,011.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$317.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24,552.75
|
| Rate for Payer: Health Management Network Commercial |
$21,968.25
|
| Rate for Payer: Humana Medicare |
$8,011.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$23,260.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13,180.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,011.95
|
| Rate for Payer: MDX Hawaii PPO |
$25,069.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,011.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,011.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15,507.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,011.95
|
| Rate for Payer: University Health Alliance Commercial |
$18,838.42
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL COMPOUNDED [4080435]
|
Facility
|
IP
|
$25,845.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21,968.25 |
| Max. Negotiated Rate |
$25,069.65 |
| Rate for Payer: Cash Price |
$15,507.00
|
| Rate for Payer: Health Management Network Commercial |
$21,968.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$23,260.50
|
| Rate for Payer: MDX Hawaii PPO |
$25,069.65
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [173366]
|
Facility
|
OP
|
$30,434.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.42 |
| Max. Negotiated Rate |
$29,520.98 |
| Rate for Payer: AlohaCare Medicaid |
$15,217.00
|
| Rate for Payer: AlohaCare Medicare |
$9,434.54
|
| Rate for Payer: Cash Price |
$18,260.40
|
| Rate for Payer: Cash Price |
$18,260.40
|
| Rate for Payer: Devoted Health Medicare |
$10,347.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$317.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$403.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,434.54
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$317.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28,912.30
|
| Rate for Payer: Health Management Network Commercial |
$25,868.90
|
| Rate for Payer: Humana Medicare |
$9,434.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$27,390.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15,521.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,434.54
|
| Rate for Payer: MDX Hawaii PPO |
$29,520.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,434.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,434.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18,260.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,434.54
|
| Rate for Payer: University Health Alliance Commercial |
$22,183.34
|
|
|
MITOMYCIN 40 MG X 2 INTRA-PYELOCALYCEAL KIT [173366]
|
Facility
|
IP
|
$30,434.00
|
|
|
Service Code
|
HCPCS J9281
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25,868.90 |
| Max. Negotiated Rate |
$29,520.98 |
| Rate for Payer: Cash Price |
$18,260.40
|
| Rate for Payer: Health Management Network Commercial |
$25,868.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$27,390.60
|
| Rate for Payer: MDX Hawaii PPO |
$29,520.98
|
|
