|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 66689003799
|
|
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
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 69315050460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$15.81
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$15.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.81
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 66689000802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$15.81
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$15.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.81
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 69315050460
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60687080040
|
|
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
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 66689003799
|
|
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
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60687080017
|
|
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
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 60432053760
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: AlohaCare Medicaid |
$30.00
|
| Rate for Payer: AlohaCare Medicare |
$18.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Devoted Health Medicare |
$20.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Humana Medicare |
$18.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.60
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 60432053760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 00121086802
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 00121086802
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$15.81
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$15.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.81
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
NYSTATIN SUSPENSION (MYCOSTATIN) 100000 UNIT/1 ML (60 ML) (TAKE HOME) [4080382]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080170
|
|
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
|
|
|
NYSTATIN SUSPENSION (MYCOSTATIN) 100000 UNIT/1 ML (60 ML) (TAKE HOME) [4080382]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080170
|
|
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
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
NDC 45802088014
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.28 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: AlohaCare Medicaid |
$44.00
|
| Rate for Payer: AlohaCare Medicare |
$27.28
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Devoted Health Medicare |
$29.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.60
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Humana Medicare |
$27.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.28
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.28
|
| Rate for Payer: University Health Alliance Commercial |
$64.14
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
NDC 45802088014
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.80 |
| Max. Negotiated Rate |
$85.36 |
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Health Management Network Commercial |
$74.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.36
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 45802024414
|
|
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
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
NDC 62332058515
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.10 |
| Max. Negotiated Rate |
$141.62 |
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Health Management Network Commercial |
$124.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.40
|
| Rate for Payer: MDX Hawaii PPO |
$141.62
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
NDC 62332058515
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.26 |
| Max. Negotiated Rate |
$141.62 |
| Rate for Payer: AlohaCare Medicaid |
$73.00
|
| Rate for Payer: AlohaCare Medicare |
$45.26
|
| Rate for Payer: Cash Price |
$87.60
|
| Rate for Payer: Devoted Health Medicare |
$49.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$138.70
|
| Rate for Payer: Health Management Network Commercial |
$124.10
|
| Rate for Payer: Humana Medicare |
$45.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$131.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$74.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.26
|
| Rate for Payer: MDX Hawaii PPO |
$141.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.26
|
| Rate for Payer: University Health Alliance Commercial |
$106.42
|
|
|
NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 45802024414
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.46 |
| 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: Devoted Health Medicare |
$22.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.46
|
| 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 Medicare |
$20.46
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [124767]
|
Facility
|
OP
|
$16,201.00
|
|
|
Service Code
|
HCPCS J9301
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.46 |
| Max. Negotiated Rate |
$15,714.97 |
| Rate for Payer: AlohaCare Medicaid |
$8,100.50
|
| Rate for Payer: AlohaCare Medicaid |
$810.50
|
| Rate for Payer: AlohaCare Medicaid |
$7,290.50
|
| Rate for Payer: AlohaCare Medicare |
$502.51
|
| Rate for Payer: AlohaCare Medicare |
$5,022.31
|
| Rate for Payer: AlohaCare Medicare |
$4,520.11
|
| Rate for Payer: Cash Price |
$8,748.60
|
| Rate for Payer: Cash Price |
$9,720.60
|
| Rate for Payer: Cash Price |
$9,720.60
|
| Rate for Payer: Cash Price |
$8,748.60
|
| Rate for Payer: Cash Price |
$972.60
|
| Rate for Payer: Cash Price |
$972.60
|
| Rate for Payer: Devoted Health Medicare |
$551.14
|
| Rate for Payer: Devoted Health Medicare |
$4,957.54
|
| Rate for Payer: Devoted Health Medicare |
$5,508.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$102.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$502.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,520.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,022.31
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$78.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$78.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13,851.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,539.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,390.95
|
| Rate for Payer: Health Management Network Commercial |
$12,393.85
|
| Rate for Payer: Health Management Network Commercial |
$1,377.85
|
| Rate for Payer: Health Management Network Commercial |
$13,770.85
|
| Rate for Payer: Humana Medicare |
$502.51
|
| Rate for Payer: Humana Medicare |
$5,022.31
|
| Rate for Payer: Humana Medicare |
$4,520.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,458.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,580.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,122.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,262.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,436.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$826.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,520.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,022.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$502.51
|
| Rate for Payer: MDX Hawaii PPO |
$1,572.37
|
| Rate for Payer: MDX Hawaii PPO |
$14,143.57
|
| Rate for Payer: MDX Hawaii PPO |
$15,714.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,520.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,022.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$502.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$502.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,022.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,520.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,748.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,720.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$972.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,022.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,520.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$502.51
|
| Rate for Payer: University Health Alliance Commercial |
$11,808.91
|
| Rate for Payer: University Health Alliance Commercial |
$1,181.55
|
| Rate for Payer: University Health Alliance Commercial |
$10,628.09
|
|
|
OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION [124767]
|
Facility
|
IP
|
$1,621.00
|
|
|
Service Code
|
HCPCS J9301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,377.85 |
| Max. Negotiated Rate |
$1,572.37 |
| Rate for Payer: Cash Price |
$972.60
|
| Rate for Payer: Cash Price |
$8,748.60
|
| Rate for Payer: Cash Price |
$9,720.60
|
| Rate for Payer: Health Management Network Commercial |
$1,377.85
|
| Rate for Payer: Health Management Network Commercial |
$13,770.85
|
| Rate for Payer: Health Management Network Commercial |
$12,393.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,122.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,580.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,458.90
|
| Rate for Payer: MDX Hawaii PPO |
$15,714.97
|
| Rate for Payer: MDX Hawaii PPO |
$14,143.57
|
| Rate for Payer: MDX Hawaii PPO |
$1,572.37
|
|
|
OBT BLADELESS-LONG 8MM 470360
|
Facility
|
OP
|
$158.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.98 |
| Max. Negotiated Rate |
$153.26 |
| Rate for Payer: AlohaCare Medicaid |
$79.00
|
| Rate for Payer: AlohaCare Medicare |
$48.98
|
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Devoted Health Medicare |
$53.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$150.10
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Humana Medicare |
$48.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.98
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.98
|
| Rate for Payer: University Health Alliance Commercial |
$115.17
|
|
|
OBT BLADELESS-LONG 8MM 470360
|
Facility
|
IP
|
$158.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.30 |
| Max. Negotiated Rate |
$153.26 |
| Rate for Payer: Cash Price |
$94.80
|
| Rate for Payer: Health Management Network Commercial |
$134.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.20
|
| Rate for Payer: MDX Hawaii PPO |
$153.26
|
|
|
OBTURATOR BLADELESS 8MM 470359
|
Facility
|
OP
|
$150.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicare |
$46.50
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Devoted Health Medicare |
$51.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$46.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.50
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.50
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
|
|
OBTURATOR BLADELESS 8MM 470359
|
Facility
|
IP
|
$150.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
|
