|
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68462063925
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68462063945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET [5604]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68462063925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
NITROGLYCERIN 1000 MCG/10 ML SYRINGE (SIMPLE) [4080323]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
NITROGLYCERIN 1000 MCG/10 ML SYRINGE (SIMPLE) [4080323]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 00281032608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
NITROGLYCERIN 2 % TRANSDERMAL OINTMENT [5606]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 00281032608
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL [27096]
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
NDC 45802021001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.22 |
| Max. Negotiated Rate |
$545.14 |
| Rate for Payer: AlohaCare Medicaid |
$281.00
|
| Rate for Payer: AlohaCare Medicare |
$174.22
|
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Devoted Health Medicare |
$191.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$533.90
|
| Rate for Payer: Health Management Network Commercial |
$477.70
|
| Rate for Payer: Humana Medicare |
$174.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$505.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$286.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.22
|
| Rate for Payer: MDX Hawaii PPO |
$545.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.22
|
| Rate for Payer: University Health Alliance Commercial |
$409.64
|
|
|
NITROGLYCERIN 400 MCG/SPRAY TRANSLINGUAL [27096]
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
NDC 45802021001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$477.70 |
| Max. Negotiated Rate |
$545.14 |
| Rate for Payer: Cash Price |
$337.20
|
| Rate for Payer: Health Management Network Commercial |
$477.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$505.80
|
| Rate for Payer: MDX Hawaii PPO |
$545.14
|
|
|
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [5599]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [5599]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Devoted Health Medicare |
$22.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Humana Medicare |
$20.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.46
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.46
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [15859]
|
Facility
|
OP
|
$99.00
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$96.03 |
| Rate for Payer: AlohaCare Medicaid |
$49.50
|
| Rate for Payer: AlohaCare Medicare |
$30.69
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Devoted Health Medicare |
$33.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.05
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Humana Medicare |
$30.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.69
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.69
|
| Rate for Payer: University Health Alliance Commercial |
$72.16
|
|
|
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS [15859]
|
Facility
|
IP
|
$99.00
|
|
|
Service Code
|
HCPCS J2305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.15 |
| Max. Negotiated Rate |
$96.03 |
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.10
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
|
|
NITROGLYCERIN TABLETS (#25) (NITROSTAT) 0.4 MG (TAKE HOME) [4080381]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080169
|
|
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
|
|
|
NITROGLYCERIN TABLETS (#25) (NITROSTAT) 0.4 MG (TAKE HOME) [4080381]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080169
|
|
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
|
|
|
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION [127844]
|
Facility
|
IP
|
$5,958.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,064.30 |
| Max. Negotiated Rate |
$5,779.26 |
| Rate for Payer: Cash Price |
$3,574.80
|
| Rate for Payer: Health Management Network Commercial |
$5,064.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,362.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,779.26
|
|
|
NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION [127844]
|
Facility
|
OP
|
$5,958.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$5,779.26 |
| Rate for Payer: AlohaCare Medicaid |
$2,979.00
|
| Rate for Payer: AlohaCare Medicare |
$1,846.98
|
| Rate for Payer: Cash Price |
$3,574.80
|
| Rate for Payer: Cash Price |
$3,574.80
|
| Rate for Payer: Devoted Health Medicare |
$2,025.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,846.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$33.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,660.10
|
| Rate for Payer: Health Management Network Commercial |
$5,064.30
|
| Rate for Payer: Humana Medicare |
$1,846.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,362.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,038.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,846.98
|
| Rate for Payer: MDX Hawaii PPO |
$5,779.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,846.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,846.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,574.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,846.98
|
| Rate for Payer: University Health Alliance Commercial |
$4,342.79
|
|
|
NIVOLUMAB 120 MG/12 ML INTRAVENOUS SOLUTION [181183]
|
Facility
|
OP
|
$7,149.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$6,934.53 |
| Rate for Payer: AlohaCare Medicaid |
$3,574.50
|
| Rate for Payer: AlohaCare Medicare |
$2,216.19
|
| Rate for Payer: Cash Price |
$4,289.40
|
| Rate for Payer: Cash Price |
$4,289.40
|
| Rate for Payer: Devoted Health Medicare |
$2,430.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,216.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$33.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,791.55
|
| Rate for Payer: Health Management Network Commercial |
$6,076.65
|
| Rate for Payer: Humana Medicare |
$2,216.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,434.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,645.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,216.19
|
| Rate for Payer: MDX Hawaii PPO |
$6,934.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,216.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,216.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,289.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,216.19
|
| Rate for Payer: University Health Alliance Commercial |
$5,210.91
|
|
|
NIVOLUMAB 120 MG/12 ML INTRAVENOUS SOLUTION [181183]
|
Facility
|
IP
|
$7,149.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,076.65 |
| Max. Negotiated Rate |
$6,934.53 |
| Rate for Payer: Cash Price |
$4,289.40
|
| Rate for Payer: Health Management Network Commercial |
$6,076.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,434.10
|
| Rate for Payer: MDX Hawaii PPO |
$6,934.53
|
|
|
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION [151108]
|
Facility
|
OP
|
$14,298.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$13,869.06 |
| Rate for Payer: AlohaCare Medicaid |
$7,149.00
|
| Rate for Payer: AlohaCare Medicaid |
$1,281.00
|
| Rate for Payer: AlohaCare Medicare |
$794.22
|
| Rate for Payer: AlohaCare Medicare |
$4,432.38
|
| Rate for Payer: Cash Price |
$1,537.20
|
| Rate for Payer: Cash Price |
$8,578.80
|
| Rate for Payer: Cash Price |
$1,537.20
|
| Rate for Payer: Cash Price |
$8,578.80
|
| Rate for Payer: Devoted Health Medicare |
$4,861.32
|
| Rate for Payer: Devoted Health Medicare |
$871.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42.02
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$794.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,432.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$33.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13,583.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,433.90
|
| Rate for Payer: Health Management Network Commercial |
$2,177.70
|
| Rate for Payer: Health Management Network Commercial |
$12,153.30
|
| Rate for Payer: Humana Medicare |
$4,432.38
|
| Rate for Payer: Humana Medicare |
$794.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$12,868.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,305.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,306.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,291.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,432.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$794.22
|
| Rate for Payer: MDX Hawaii PPO |
$13,869.06
|
| Rate for Payer: MDX Hawaii PPO |
$2,485.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$794.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,432.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,432.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$794.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,537.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,578.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,432.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$794.22
|
| Rate for Payer: University Health Alliance Commercial |
$10,421.81
|
| Rate for Payer: University Health Alliance Commercial |
$1,867.44
|
|
|
NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION [151108]
|
Facility
|
IP
|
$14,298.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12,153.30 |
| Max. Negotiated Rate |
$13,869.06 |
| Rate for Payer: Cash Price |
$8,578.80
|
| Rate for Payer: Cash Price |
$1,537.20
|
| Rate for Payer: Health Management Network Commercial |
$12,153.30
|
| Rate for Payer: Health Management Network Commercial |
$2,177.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$12,868.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,305.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,485.14
|
| Rate for Payer: MDX Hawaii PPO |
$13,869.06
|
|
|
NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION [184158]
|
Facility
|
IP
|
$27,760.00
|
|
|
Service Code
|
HCPCS J9298
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23,596.00 |
| Max. Negotiated Rate |
$26,927.20 |
| Rate for Payer: Cash Price |
$16,656.00
|
| Rate for Payer: Health Management Network Commercial |
$23,596.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$24,984.00
|
| Rate for Payer: MDX Hawaii PPO |
$26,927.20
|
|
|
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION [127843]
|
Facility
|
OP
|
$2,383.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$2,311.51 |
| Rate for Payer: AlohaCare Medicaid |
$1,191.50
|
| Rate for Payer: AlohaCare Medicare |
$738.73
|
| Rate for Payer: Cash Price |
$1,429.80
|
| Rate for Payer: Cash Price |
$1,429.80
|
| Rate for Payer: Devoted Health Medicare |
$810.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$33.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$738.73
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$33.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,263.85
|
| Rate for Payer: Health Management Network Commercial |
$2,025.55
|
| Rate for Payer: Humana Medicare |
$738.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,144.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,215.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$738.73
|
| Rate for Payer: MDX Hawaii PPO |
$2,311.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$738.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$738.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,429.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$738.73
|
| Rate for Payer: University Health Alliance Commercial |
$1,736.97
|
|
|
NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION [127843]
|
Facility
|
IP
|
$2,383.00
|
|
|
Service Code
|
HCPCS J9299
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,025.55 |
| Max. Negotiated Rate |
$2,311.51 |
| Rate for Payer: Cash Price |
$1,429.80
|
| Rate for Payer: Health Management Network Commercial |
$2,025.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,144.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,311.51
|
|
|
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC
|
Facility
|
IP
|
$37,543.97
|
|
|
Service Code
|
MSDRG 098
|
| Min. Negotiated Rate |
$37,543.97 |
| Max. Negotiated Rate |
$37,543.97 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$37,543.97
|
|
