|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084038911
|
|
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
|
|
|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084038901
|
|
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
|
|
|
BENZTROPINE 2 MG TABLET [1000]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084038911
|
|
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
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
HCPCS J0702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.89 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: AlohaCare Medicaid |
$83.00
|
| Rate for Payer: AlohaCare Medicare |
$51.46
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Devoted Health Medicare |
$56.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$157.70
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Humana Medicare |
$51.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.46
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$99.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.46
|
| Rate for Payer: University Health Alliance Commercial |
$121.00
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9266]
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
HCPCS J0702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.10 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: Cash Price |
$99.60
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM [1031]
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 00168004046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.00
|
| Rate for Payer: MDX Hawaii PPO |
$194.00
|
|
|
BETAMETHASONE VALERATE 0.1 % TOPICAL CREAM [1031]
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
NDC 00168004046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: AlohaCare Medicaid |
$100.00
|
| Rate for Payer: AlohaCare Medicare |
$62.00
|
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Devoted Health Medicare |
$68.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.00
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Humana Medicare |
$62.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.00
|
| Rate for Payer: MDX Hawaii PPO |
$194.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.00
|
| Rate for Payer: University Health Alliance Commercial |
$145.78
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00832051200
|
|
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
|
|
|
BETHANECHOL CHLORIDE 25 MG TABLET [1044]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00832051200
|
|
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
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [108065]
|
Facility
|
OP
|
$3,290.00
|
|
|
Service Code
|
HCPCS J9035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$73.05 |
| Max. Negotiated Rate |
$3,191.30 |
| Rate for Payer: AlohaCare Medicaid |
$1,645.00
|
| Rate for Payer: AlohaCare Medicaid |
$3,060.50
|
| Rate for Payer: AlohaCare Medicaid |
$717.50
|
| Rate for Payer: AlohaCare Medicare |
$1,897.51
|
| Rate for Payer: AlohaCare Medicare |
$1,019.90
|
| Rate for Payer: AlohaCare Medicare |
$444.85
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cash Price |
$1,974.00
|
| Rate for Payer: Cash Price |
$1,974.00
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cash Price |
$3,672.60
|
| Rate for Payer: Cash Price |
$3,672.60
|
| Rate for Payer: Devoted Health Medicare |
$2,081.14
|
| Rate for Payer: Devoted Health Medicare |
$487.90
|
| Rate for Payer: Devoted Health Medicare |
$1,118.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$73.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$73.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$73.05
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$92.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$92.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$92.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,897.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$444.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,019.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$73.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$73.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$73.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,363.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,814.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,125.50
|
| Rate for Payer: Health Management Network Commercial |
$1,219.75
|
| Rate for Payer: Health Management Network Commercial |
$5,202.85
|
| Rate for Payer: Health Management Network Commercial |
$2,796.50
|
| Rate for Payer: Humana Medicare |
$1,897.51
|
| Rate for Payer: Humana Medicare |
$1,019.90
|
| Rate for Payer: Humana Medicare |
$444.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,508.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,961.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,291.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,677.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$731.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,121.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$444.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,019.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,897.51
|
| Rate for Payer: MDX Hawaii PPO |
$5,937.37
|
| Rate for Payer: MDX Hawaii PPO |
$1,391.95
|
| Rate for Payer: MDX Hawaii PPO |
$3,191.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$444.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,019.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,897.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,897.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,019.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$444.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$861.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,974.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,672.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,019.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$444.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,897.51
|
| Rate for Payer: University Health Alliance Commercial |
$2,398.08
|
| Rate for Payer: University Health Alliance Commercial |
$4,461.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,045.97
|
|
|
BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [108065]
|
Facility
|
IP
|
$6,121.00
|
|
|
Service Code
|
HCPCS J9035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,202.85 |
| Max. Negotiated Rate |
$5,937.37 |
| Rate for Payer: Cash Price |
$3,672.60
|
| Rate for Payer: Cash Price |
$861.00
|
| Rate for Payer: Cash Price |
$1,974.00
|
| Rate for Payer: Health Management Network Commercial |
$5,202.85
|
| Rate for Payer: Health Management Network Commercial |
$2,796.50
|
| Rate for Payer: Health Management Network Commercial |
$1,219.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,291.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,961.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,508.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,191.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,391.95
|
| Rate for Payer: MDX Hawaii PPO |
$5,937.37
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [168888]
|
Facility
|
IP
|
$5,359.00
|
|
|
Service Code
|
HCPCS Q5107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,555.15 |
| Max. Negotiated Rate |
$5,198.23 |
| Rate for Payer: Cash Price |
$3,215.40
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Health Management Network Commercial |
$4,555.15
|
| Rate for Payer: Health Management Network Commercial |
$2,448.85
|
| Rate for Payer: Health Management Network Commercial |
$1,067.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,130.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,592.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,823.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,794.57
|
| Rate for Payer: MDX Hawaii PPO |
$1,218.32
|
| Rate for Payer: MDX Hawaii PPO |
$5,198.23
|
|
|
BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION [168888]
|
Facility
|
OP
|
$2,881.00
|
|
|
Service Code
|
HCPCS Q5107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.85 |
| Max. Negotiated Rate |
$2,794.57 |
| Rate for Payer: AlohaCare Medicaid |
$1,440.50
|
| Rate for Payer: AlohaCare Medicaid |
$2,679.50
|
| Rate for Payer: AlohaCare Medicaid |
$628.00
|
| Rate for Payer: AlohaCare Medicare |
$1,661.29
|
| Rate for Payer: AlohaCare Medicare |
$893.11
|
| Rate for Payer: AlohaCare Medicare |
$389.36
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cash Price |
$1,728.60
|
| Rate for Payer: Cash Price |
$753.60
|
| Rate for Payer: Cash Price |
$3,215.40
|
| Rate for Payer: Cash Price |
$3,215.40
|
| Rate for Payer: Devoted Health Medicare |
$1,822.06
|
| Rate for Payer: Devoted Health Medicare |
$427.04
|
| Rate for Payer: Devoted Health Medicare |
$979.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.85
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,661.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$389.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$893.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,193.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,091.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,736.95
|
| Rate for Payer: Health Management Network Commercial |
$1,067.60
|
| Rate for Payer: Health Management Network Commercial |
$4,555.15
|
| Rate for Payer: Health Management Network Commercial |
$2,448.85
|
| Rate for Payer: Humana Medicare |
$1,661.29
|
| Rate for Payer: Humana Medicare |
$893.11
|
| Rate for Payer: Humana Medicare |
$389.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,823.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,592.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,130.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,469.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$640.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,733.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$389.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$893.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,661.29
|
| Rate for Payer: MDX Hawaii PPO |
$5,198.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,218.32
|
| Rate for Payer: MDX Hawaii PPO |
$2,794.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$389.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$893.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,661.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,661.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$893.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$389.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$753.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,728.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,215.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$893.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$389.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,661.29
|
| Rate for Payer: University Health Alliance Commercial |
$2,099.96
|
| Rate for Payer: University Health Alliance Commercial |
$3,906.18
|
| Rate for Payer: University Health Alliance Commercial |
$915.50
|
|
|
BFLEX 2 2.8 0570-0447
|
Facility
|
IP
|
$1,260.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,071.00 |
| Max. Negotiated Rate |
$1,222.20 |
| Rate for Payer: Cash Price |
$756.00
|
| Rate for Payer: Health Management Network Commercial |
$1,071.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,134.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,222.20
|
|
|
BFLEX 2 2.8 0570-0447
|
Facility
|
OP
|
$1,260.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$390.60 |
| Max. Negotiated Rate |
$1,222.20 |
| Rate for Payer: AlohaCare Medicaid |
$630.00
|
| Rate for Payer: AlohaCare Medicare |
$390.60
|
| Rate for Payer: Cash Price |
$756.00
|
| Rate for Payer: Devoted Health Medicare |
$428.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$390.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,197.00
|
| Rate for Payer: Health Management Network Commercial |
$1,071.00
|
| Rate for Payer: Humana Medicare |
$390.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,134.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$642.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$390.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,222.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$390.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$390.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$390.60
|
| Rate for Payer: University Health Alliance Commercial |
$918.41
|
|
|
BFLEX 2 5.0 0570-0449
|
Facility
|
OP
|
$1,050.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$325.50 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: AlohaCare Medicaid |
$525.00
|
| Rate for Payer: AlohaCare Medicare |
$325.50
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Devoted Health Medicare |
$357.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$325.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$997.50
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Humana Medicare |
$325.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$945.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$535.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$325.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$325.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$325.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$325.50
|
| Rate for Payer: University Health Alliance Commercial |
$765.35
|
|
|
BFLEX 2 5.0 0570-0449
|
Facility
|
IP
|
$1,050.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$1,018.50 |
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: Health Management Network Commercial |
$892.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$945.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,018.50
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$46.00
|
|
|
Service Code
|
NDC 16729002310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.10 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 00310070530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$46.00
|
|
|
Service Code
|
NDC 16729002310
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.26 |
| Max. Negotiated Rate |
$44.62 |
| Rate for Payer: AlohaCare Medicaid |
$23.00
|
| Rate for Payer: AlohaCare Medicare |
$14.26
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Devoted Health Medicare |
$15.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.70
|
| Rate for Payer: Health Management Network Commercial |
$39.10
|
| Rate for Payer: Humana Medicare |
$14.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.26
|
| Rate for Payer: MDX Hawaii PPO |
$44.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.26
|
| Rate for Payer: University Health Alliance Commercial |
$33.53
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 47335048583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
NDC 00310070530
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$15.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$14.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.57
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.57
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
BICALUTAMIDE 50 MG TABLET [15746]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
NDC 47335048583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$15.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$14.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.57
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.57
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
BIILATERAL KIT W/PDS 0 ES0529
|
Facility
|
IP
|
$1,383.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$774.48 |
| Max. Negotiated Rate |
$1,341.51 |
| Rate for Payer: Cash Price |
$829.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$968.10
|
| Rate for Payer: Health Management Network Commercial |
$1,175.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,244.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,341.51
|
| Rate for Payer: University Health Alliance Commercial |
$774.48
|
|
|
BIILATERAL KIT W/PDS 0 ES0529
|
Facility
|
OP
|
$1,383.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$428.73 |
| Max. Negotiated Rate |
$1,341.51 |
| Rate for Payer: AlohaCare Medicaid |
$691.50
|
| Rate for Payer: AlohaCare Medicare |
$428.73
|
| Rate for Payer: Cash Price |
$829.80
|
| Rate for Payer: Devoted Health Medicare |
$470.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$428.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$968.10
|
| Rate for Payer: Health Management Network Commercial |
$1,175.55
|
| Rate for Payer: Humana Medicare |
$428.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,244.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$705.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$428.73
|
| Rate for Payer: MDX Hawaii PPO |
$1,341.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$428.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$428.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$428.73
|
| Rate for Payer: University Health Alliance Commercial |
$774.48
|
|
