|
PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION [34034]
|
Facility
|
OP
|
$1,837.00
|
|
|
Service Code
|
HCPCS S0145
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$569.47 |
| Max. Negotiated Rate |
$1,781.89 |
| Rate for Payer: AlohaCare Medicaid |
$918.50
|
| Rate for Payer: AlohaCare Medicare |
$569.47
|
| Rate for Payer: Cash Price |
$1,102.20
|
| Rate for Payer: Devoted Health Medicare |
$624.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$569.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,745.15
|
| Rate for Payer: Health Management Network Commercial |
$1,561.45
|
| Rate for Payer: Humana Medicare |
$569.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,653.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$936.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$569.47
|
| Rate for Payer: MDX Hawaii PPO |
$1,781.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$569.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$569.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,102.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$569.47
|
| Rate for Payer: University Health Alliance Commercial |
$1,338.99
|
|
|
PEG KIT 20FR M00568201
|
Facility
|
IP
|
$240.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$204.00 |
| Max. Negotiated Rate |
$232.80 |
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
|
|
PEG KIT 20FR M00568201
|
Facility
|
OP
|
$240.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.40 |
| Max. Negotiated Rate |
$232.80 |
| Rate for Payer: AlohaCare Medicaid |
$120.00
|
| Rate for Payer: AlohaCare Medicare |
$74.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Devoted Health Medicare |
$81.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$228.00
|
| Rate for Payer: Health Management Network Commercial |
$204.00
|
| Rate for Payer: Humana Medicare |
$74.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$216.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.40
|
| Rate for Payer: MDX Hawaii PPO |
$232.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.40
|
| Rate for Payer: University Health Alliance Commercial |
$174.94
|
|
|
PEG OXFORD FEMORAL TWIN MED
|
Facility
|
OP
|
$3,840.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.40 |
| Max. Negotiated Rate |
$3,724.80 |
| Rate for Payer: AlohaCare Medicaid |
$1,920.00
|
| Rate for Payer: AlohaCare Medicare |
$1,190.40
|
| Rate for Payer: Cash Price |
$2,304.00
|
| Rate for Payer: Devoted Health Medicare |
$1,305.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,190.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,688.00
|
| Rate for Payer: Health Management Network Commercial |
$3,264.00
|
| Rate for Payer: Humana Medicare |
$1,190.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,456.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,958.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,190.40
|
| Rate for Payer: MDX Hawaii PPO |
$3,724.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,190.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,190.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,190.40
|
| Rate for Payer: University Health Alliance Commercial |
$2,150.40
|
|
|
PEG OXFORD FEMORAL TWIN MED
|
Facility
|
IP
|
$3,840.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.40 |
| Max. Negotiated Rate |
$3,724.80 |
| Rate for Payer: Cash Price |
$2,304.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,688.00
|
| Rate for Payer: Health Management Network Commercial |
$3,264.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,456.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,724.80
|
| Rate for Payer: University Health Alliance Commercial |
$2,150.40
|
|
|
PEG THREADED 2.5X20MM TP20
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: AlohaCare Medicaid |
$300.00
|
| Rate for Payer: AlohaCare Medicare |
$186.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Devoted Health Medicare |
$204.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$420.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Humana Medicare |
$186.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.00
|
| Rate for Payer: University Health Alliance Commercial |
$336.00
|
|
|
PEG THREADED 2.5X20MM TP20
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$420.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: University Health Alliance Commercial |
$336.00
|
|
|
PEG THREADED 2.5X24MM TP24
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$336.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$420.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: University Health Alliance Commercial |
$336.00
|
|
|
PEG THREADED 2.5X24MM TP24
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: AlohaCare Medicaid |
$300.00
|
| Rate for Payer: AlohaCare Medicare |
$186.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Devoted Health Medicare |
$204.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$420.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Humana Medicare |
$186.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.00
|
| Rate for Payer: University Health Alliance Commercial |
$336.00
|
|
|
PEG THREADED 2.5X30MM TP30000
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.52 |
| Max. Negotiated Rate |
$404.49 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.90
|
| Rate for Payer: Health Management Network Commercial |
$354.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$375.30
|
| Rate for Payer: MDX Hawaii PPO |
$404.49
|
| Rate for Payer: University Health Alliance Commercial |
$233.52
|
|
|
PEG THREADED 2.5X30MM TP30000
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$129.27 |
| Max. Negotiated Rate |
$404.49 |
| Rate for Payer: AlohaCare Medicaid |
$208.50
|
| Rate for Payer: AlohaCare Medicare |
$129.27
|
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Devoted Health Medicare |
$141.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$129.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.90
|
| Rate for Payer: Health Management Network Commercial |
$354.45
|
| Rate for Payer: Humana Medicare |
$129.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$375.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$129.27
|
| Rate for Payer: MDX Hawaii PPO |
$404.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$129.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$129.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$129.27
|
| Rate for Payer: University Health Alliance Commercial |
$233.52
|
|
|
PEG TWIG FEMUR SMALL
|
Facility
|
OP
|
$3,840.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.40 |
| Max. Negotiated Rate |
$3,724.80 |
| Rate for Payer: AlohaCare Medicaid |
$1,920.00
|
| Rate for Payer: AlohaCare Medicare |
$1,190.40
|
| Rate for Payer: Cash Price |
$2,304.00
|
| Rate for Payer: Devoted Health Medicare |
$1,305.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,190.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,688.00
|
| Rate for Payer: Health Management Network Commercial |
$3,264.00
|
| Rate for Payer: Humana Medicare |
$1,190.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,456.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,958.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,190.40
|
| Rate for Payer: MDX Hawaii PPO |
$3,724.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,190.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,190.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,190.40
|
| Rate for Payer: University Health Alliance Commercial |
$2,150.40
|
|
|
PEG TWIG FEMUR SMALL
|
Facility
|
IP
|
$3,840.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.40 |
| Max. Negotiated Rate |
$3,724.80 |
| Rate for Payer: Cash Price |
$2,304.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,688.00
|
| Rate for Payer: Health Management Network Commercial |
$3,264.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,456.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,724.80
|
| Rate for Payer: University Health Alliance Commercial |
$2,150.40
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC
|
Facility
|
IP
|
$39,487.53
|
|
|
Service Code
|
MSDRG 734
|
| Min. Negotiated Rate |
$39,487.53 |
| Max. Negotiated Rate |
$39,487.53 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39,487.53
|
|
|
PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$39,487.53
|
|
|
Service Code
|
MSDRG 735
|
| Min. Negotiated Rate |
$39,487.53 |
| Max. Negotiated Rate |
$39,487.53 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39,487.53
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [127964]
|
Facility
|
OP
|
$14,938.00
|
|
|
Service Code
|
HCPCS J9271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.56 |
| Max. Negotiated Rate |
$14,489.86 |
| Rate for Payer: AlohaCare Medicaid |
$7,469.00
|
| Rate for Payer: AlohaCare Medicaid |
$3,859.50
|
| Rate for Payer: AlohaCare Medicare |
$2,392.89
|
| Rate for Payer: AlohaCare Medicare |
$4,630.78
|
| Rate for Payer: Cash Price |
$8,962.80
|
| Rate for Payer: Cash Price |
$8,962.80
|
| Rate for Payer: Cash Price |
$4,631.40
|
| Rate for Payer: Cash Price |
$4,631.40
|
| Rate for Payer: Devoted Health Medicare |
$5,078.92
|
| Rate for Payer: Devoted Health Medicare |
$2,624.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$58.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$58.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$76.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$76.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,630.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,392.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$58.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$58.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,191.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,333.05
|
| Rate for Payer: Health Management Network Commercial |
$12,697.30
|
| Rate for Payer: Health Management Network Commercial |
$6,561.15
|
| Rate for Payer: Humana Medicare |
$4,630.78
|
| Rate for Payer: Humana Medicare |
$2,392.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,444.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,947.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,618.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,936.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,630.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,392.89
|
| Rate for Payer: MDX Hawaii PPO |
$14,489.86
|
| Rate for Payer: MDX Hawaii PPO |
$7,487.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,392.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,630.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,630.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,392.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,962.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,631.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,392.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,630.78
|
| Rate for Payer: University Health Alliance Commercial |
$10,888.31
|
| Rate for Payer: University Health Alliance Commercial |
$5,626.38
|
|
|
PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION [127964]
|
Facility
|
IP
|
$14,938.00
|
|
|
Service Code
|
HCPCS J9271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12,697.30 |
| Max. Negotiated Rate |
$14,489.86 |
| Rate for Payer: Cash Price |
$8,962.80
|
| Rate for Payer: Cash Price |
$4,631.40
|
| Rate for Payer: Health Management Network Commercial |
$6,561.15
|
| Rate for Payer: Health Management Network Commercial |
$12,697.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,444.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,947.10
|
| Rate for Payer: MDX Hawaii PPO |
$14,489.86
|
| Rate for Payer: MDX Hawaii PPO |
$7,487.43
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
|
|
PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION [89350]
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$27.90
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$30.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$27.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.90
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.90
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL) [43037894]
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$229.50 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
|
|
PEMETREXED DISODIUM 500 MG/20ML IV (WET SOLR VIAL) [43037894]
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: AlohaCare Medicaid |
$135.00
|
| Rate for Payer: AlohaCare Medicare |
$83.70
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$91.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.50
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Humana Medicare |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.70
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$162.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.70
|
| Rate for Payer: University Health Alliance Commercial |
$196.80
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: AlohaCare Medicaid |
$135.00
|
| Rate for Payer: AlohaCare Medicare |
$83.70
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$91.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.73
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.50
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Humana Medicare |
$83.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.70
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$162.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.70
|
| Rate for Payer: University Health Alliance Commercial |
$196.80
|
|
|
PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION [37894]
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
HCPCS J9305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$229.50 |
| Max. Negotiated Rate |
$261.90 |
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
|
|
PENCIL SMOKE EVACUATION ROCKER
|
Facility
|
IP
|
$207.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$175.95 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Health Management Network Commercial |
$175.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$186.30
|
| Rate for Payer: MDX Hawaii PPO |
$200.79
|
|
|
PENCIL SMOKE EVACUATION ROCKER
|
Facility
|
OP
|
$207.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.17 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: AlohaCare Medicaid |
$103.50
|
| Rate for Payer: AlohaCare Medicare |
$64.17
|
| Rate for Payer: Cash Price |
$124.20
|
| Rate for Payer: Devoted Health Medicare |
$70.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$64.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$196.65
|
| Rate for Payer: Health Management Network Commercial |
$175.95
|
| Rate for Payer: Humana Medicare |
$64.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$186.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$64.17
|
| Rate for Payer: MDX Hawaii PPO |
$200.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$64.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$64.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$64.17
|
| Rate for Payer: University Health Alliance Commercial |
$150.88
|
|