|
BEARING TIB #3 X3 5532-G-311-E
|
Facility
|
OP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.93 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: AlohaCare Medicaid |
$1,351.50
|
| Rate for Payer: AlohaCare Medicare |
$837.93
|
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Devoted Health Medicare |
$919.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$837.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Humana Medicare |
$837.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,378.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$837.93
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$837.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$837.93
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIB #3 X3 5532-G-311-E
|
Facility
|
IP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,513.68 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIB 5X11MM 5532-G-511
|
Facility
|
OP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.93 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: AlohaCare Medicaid |
$1,351.50
|
| Rate for Payer: AlohaCare Medicare |
$837.93
|
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Devoted Health Medicare |
$919.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$837.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Humana Medicare |
$837.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,378.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$837.93
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$837.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$837.93
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIB 5X11MM 5532-G-511
|
Facility
|
IP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,513.68 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIBIAL 5X13 5532-G-513
|
Facility
|
IP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,513.68 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIBIAL 5X13 5532-G-513
|
Facility
|
OP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.93 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: AlohaCare Medicaid |
$1,351.50
|
| Rate for Payer: AlohaCare Medicare |
$837.93
|
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Devoted Health Medicare |
$919.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$837.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Humana Medicare |
$837.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,378.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$837.93
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$837.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$837.93
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIBIAL 8X13 5532-G-813
|
Facility
|
OP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.93 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: AlohaCare Medicaid |
$1,351.50
|
| Rate for Payer: AlohaCare Medicare |
$837.93
|
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Devoted Health Medicare |
$919.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$837.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Humana Medicare |
$837.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,378.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$837.93
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$837.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$837.93
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIBIAL 8X13 5532-G-813
|
Facility
|
IP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,513.68 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIBIAL X3 5531-G-611-E
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$829.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,338.00
|
| Rate for Payer: AlohaCare Medicare |
$829.56
|
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Devoted Health Medicare |
$909.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$829.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Humana Medicare |
$829.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,364.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$829.56
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$829.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$829.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$829.56
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
BEARING TIBIAL X3 5531-G-611-E
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
BEARING TIB SZ#3 X3 5532-G-311
|
Facility
|
IP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,513.68 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEARING TIB SZ#3 X3 5532-G-311
|
Facility
|
OP
|
$2,703.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$837.93 |
| Max. Negotiated Rate |
$2,621.91 |
| Rate for Payer: AlohaCare Medicaid |
$1,351.50
|
| Rate for Payer: AlohaCare Medicare |
$837.93
|
| Rate for Payer: Cash Price |
$1,621.80
|
| Rate for Payer: Devoted Health Medicare |
$919.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$837.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,892.10
|
| Rate for Payer: Health Management Network Commercial |
$2,297.55
|
| Rate for Payer: Humana Medicare |
$837.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,432.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,378.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$837.93
|
| Rate for Payer: MDX Hawaii PPO |
$2,621.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$837.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$837.93
|
| Rate for Payer: University Health Alliance Commercial |
$1,513.68
|
|
|
BEAUTI BOND S23-2149
|
Facility
|
IP
|
$540.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$459.00 |
| Max. Negotiated Rate |
$523.80 |
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Health Management Network Commercial |
$459.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$486.00
|
| Rate for Payer: MDX Hawaii PPO |
$523.80
|
|
|
BEAUTI BOND S23-2149
|
Facility
|
OP
|
$540.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.40 |
| Max. Negotiated Rate |
$523.80 |
| Rate for Payer: AlohaCare Medicaid |
$270.00
|
| Rate for Payer: AlohaCare Medicare |
$167.40
|
| Rate for Payer: Cash Price |
$324.00
|
| Rate for Payer: Devoted Health Medicare |
$183.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$167.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$513.00
|
| Rate for Payer: Health Management Network Commercial |
$459.00
|
| Rate for Payer: Humana Medicare |
$167.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$486.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$275.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$167.40
|
| Rate for Payer: MDX Hawaii PPO |
$523.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$167.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$167.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$167.40
|
| Rate for Payer: University Health Alliance Commercial |
$393.61
|
|
|
BEHAVIORAL AND DEVELOPMENTAL DISORDERS
|
Facility
|
IP
|
$14,126.39
|
|
|
Service Code
|
MSDRG 886
|
| Min. Negotiated Rate |
$14,126.39 |
| Max. Negotiated Rate |
$14,126.39 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,126.39
|
|
|
BELL SHAPE BODY HOOD PROTECTOR
|
Facility
|
IP
|
$125.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
|
|
BELL SHAPE BODY HOOD PROTECTOR
|
Facility
|
OP
|
$125.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.75 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: AlohaCare Medicaid |
$62.50
|
| Rate for Payer: AlohaCare Medicare |
$38.75
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Devoted Health Medicare |
$42.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.75
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Humana Medicare |
$38.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.75
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.75
|
| Rate for Payer: University Health Alliance Commercial |
$91.11
|
|
|
BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION [91300]
|
Facility
|
OP
|
$4,067.00
|
|
|
Service Code
|
HCPCS J9033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$3,944.99 |
| Rate for Payer: AlohaCare Medicaid |
$2,033.50
|
| Rate for Payer: AlohaCare Medicaid |
$315.00
|
| Rate for Payer: AlohaCare Medicare |
$195.30
|
| Rate for Payer: AlohaCare Medicare |
$1,260.77
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cash Price |
$2,440.20
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cash Price |
$2,440.20
|
| Rate for Payer: Devoted Health Medicare |
$1,382.78
|
| Rate for Payer: Devoted Health Medicare |
$214.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.85
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.70
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$195.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,260.77
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,863.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$598.50
|
| Rate for Payer: Health Management Network Commercial |
$535.50
|
| Rate for Payer: Health Management Network Commercial |
$3,456.95
|
| Rate for Payer: Humana Medicare |
$1,260.77
|
| Rate for Payer: Humana Medicare |
$195.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,660.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$321.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,074.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,260.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$195.30
|
| Rate for Payer: MDX Hawaii PPO |
$3,944.99
|
| Rate for Payer: MDX Hawaii PPO |
$611.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$195.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,260.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,260.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$195.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$378.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,440.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,260.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$195.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,964.44
|
| Rate for Payer: University Health Alliance Commercial |
$459.21
|
|
|
BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION [91300]
|
Facility
|
IP
|
$4,067.00
|
|
|
Service Code
|
HCPCS J9033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,456.95 |
| Max. Negotiated Rate |
$3,944.99 |
| Rate for Payer: Cash Price |
$2,440.20
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Health Management Network Commercial |
$3,456.95
|
| Rate for Payer: Health Management Network Commercial |
$535.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,660.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$567.00
|
| Rate for Payer: MDX Hawaii PPO |
$611.10
|
| Rate for Payer: MDX Hawaii PPO |
$3,944.99
|
|
|
BENDAMUSTINE HCL 100 MG/4ML IV SOLN (BENDEKA) [440131644]
|
Facility
|
IP
|
$4,453.00
|
|
|
Service Code
|
HCPCS J9034
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,785.05 |
| Max. Negotiated Rate |
$4,319.41 |
| Rate for Payer: Cash Price |
$2,671.80
|
| Rate for Payer: Cash Price |
$3,559.20
|
| Rate for Payer: Health Management Network Commercial |
$3,785.05
|
| Rate for Payer: Health Management Network Commercial |
$5,042.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,007.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,338.80
|
| Rate for Payer: MDX Hawaii PPO |
$5,754.04
|
| Rate for Payer: MDX Hawaii PPO |
$4,319.41
|
|
|
BENDAMUSTINE HCL 100 MG/4ML IV SOLN (BENDEKA) [440131644]
|
Facility
|
OP
|
$4,453.00
|
|
|
Service Code
|
HCPCS J9034
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$4,319.41 |
| Rate for Payer: AlohaCare Medicaid |
$2,226.50
|
| Rate for Payer: AlohaCare Medicaid |
$2,966.00
|
| Rate for Payer: AlohaCare Medicare |
$1,838.92
|
| Rate for Payer: AlohaCare Medicare |
$1,380.43
|
| Rate for Payer: Cash Price |
$3,559.20
|
| Rate for Payer: Cash Price |
$2,671.80
|
| Rate for Payer: Cash Price |
$3,559.20
|
| Rate for Payer: Cash Price |
$2,671.80
|
| Rate for Payer: Devoted Health Medicare |
$1,514.02
|
| Rate for Payer: Devoted Health Medicare |
$2,016.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$13.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$13.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,838.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,380.43
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,230.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,635.40
|
| Rate for Payer: Health Management Network Commercial |
$5,042.20
|
| Rate for Payer: Health Management Network Commercial |
$3,785.05
|
| Rate for Payer: Humana Medicare |
$1,380.43
|
| Rate for Payer: Humana Medicare |
$1,838.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,007.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,338.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,025.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,271.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,380.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,838.92
|
| Rate for Payer: MDX Hawaii PPO |
$4,319.41
|
| Rate for Payer: MDX Hawaii PPO |
$5,754.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,838.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,380.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,380.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,838.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,559.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,671.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,380.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,838.92
|
| Rate for Payer: University Health Alliance Commercial |
$3,245.79
|
| Rate for Payer: University Health Alliance Commercial |
$4,323.83
|
|
|
BENDAMUSTINE HCL 100 MG/4ML IV SOLN (UNBRANDED) [131577]
|
Facility
|
IP
|
$4,212.00
|
|
|
Service Code
|
HCPCS J9036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,580.20 |
| Max. Negotiated Rate |
$4,085.64 |
| Rate for Payer: Cash Price |
$2,527.20
|
| Rate for Payer: Cash Price |
$2,618.40
|
| Rate for Payer: Health Management Network Commercial |
$3,580.20
|
| Rate for Payer: Health Management Network Commercial |
$3,709.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,790.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,927.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,233.08
|
| Rate for Payer: MDX Hawaii PPO |
$4,085.64
|
|
|
BENDAMUSTINE HCL 100 MG/4ML IV SOLN (UNBRANDED) [131577]
|
Facility
|
OP
|
$4,212.00
|
|
|
Service Code
|
HCPCS J9036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$4,085.64 |
| Rate for Payer: AlohaCare Medicaid |
$2,106.00
|
| Rate for Payer: AlohaCare Medicaid |
$2,182.00
|
| Rate for Payer: AlohaCare Medicare |
$1,352.84
|
| Rate for Payer: AlohaCare Medicare |
$1,305.72
|
| Rate for Payer: Cash Price |
$2,618.40
|
| Rate for Payer: Cash Price |
$2,527.20
|
| Rate for Payer: Cash Price |
$2,618.40
|
| Rate for Payer: Cash Price |
$2,527.20
|
| Rate for Payer: Devoted Health Medicare |
$1,432.08
|
| Rate for Payer: Devoted Health Medicare |
$1,483.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.99
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.99
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,352.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,305.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,001.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,145.80
|
| Rate for Payer: Health Management Network Commercial |
$3,709.40
|
| Rate for Payer: Health Management Network Commercial |
$3,580.20
|
| Rate for Payer: Humana Medicare |
$1,305.72
|
| Rate for Payer: Humana Medicare |
$1,352.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,790.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,927.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,225.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,148.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,305.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,352.84
|
| Rate for Payer: MDX Hawaii PPO |
$4,085.64
|
| Rate for Payer: MDX Hawaii PPO |
$4,233.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,352.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,305.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,305.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,352.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,618.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,527.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,305.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,352.84
|
| Rate for Payer: University Health Alliance Commercial |
$3,070.13
|
| Rate for Payer: University Health Alliance Commercial |
$3,180.92
|
|
|
BENDING TEMPLATE
|
Facility
|
IP
|
$668.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$567.80 |
| Max. Negotiated Rate |
$647.96 |
| Rate for Payer: Cash Price |
$400.80
|
| Rate for Payer: Health Management Network Commercial |
$567.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$601.20
|
| Rate for Payer: MDX Hawaii PPO |
$647.96
|
|
|
BENDING TEMPLATE
|
Facility
|
OP
|
$668.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$207.08 |
| Max. Negotiated Rate |
$647.96 |
| Rate for Payer: AlohaCare Medicaid |
$334.00
|
| Rate for Payer: AlohaCare Medicare |
$207.08
|
| Rate for Payer: Cash Price |
$400.80
|
| Rate for Payer: Devoted Health Medicare |
$227.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$634.60
|
| Rate for Payer: Health Management Network Commercial |
$567.80
|
| Rate for Payer: Humana Medicare |
$207.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$601.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$340.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.08
|
| Rate for Payer: MDX Hawaii PPO |
$647.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.08
|
| Rate for Payer: University Health Alliance Commercial |
$486.91
|
|
