|
FEMUR SPHERE R6+ 02.12.0026R
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.00 |
| Max. Negotiated Rate |
$3,880.00 |
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,800.00
|
| Rate for Payer: Health Management Network Commercial |
$3,400.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,520.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,040.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,880.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,240.00
|
|
|
FEMUR SPH LEFT S3+ 02.12.0023L
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,240.00 |
| Max. Negotiated Rate |
$3,880.00 |
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,800.00
|
| Rate for Payer: Health Management Network Commercial |
$3,400.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,880.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,240.00
|
|
|
FEMUR SPH LEFT S3+ 02.12.0023L
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,040.00 |
| Max. Negotiated Rate |
$3,880.00 |
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,800.00
|
| Rate for Payer: Health Management Network Commercial |
$3,400.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,520.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,040.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,880.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,240.00
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET [40010]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00378306677
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET [40010]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 00378306677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET [40009]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 65862076890
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET [40009]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 65862076890
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET [40009]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00378306577
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET [40009]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 50268033812
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET [40009]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 50268033812
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET [40009]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00378306577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
NDC 00378912416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
NDC 00378912498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
NDC 00406910076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
NDC 00378912416
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.57 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.65
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: University Health Alliance Commercial |
$77.99
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
NDC 00378912498
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.57 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.65
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: University Health Alliance Commercial |
$77.99
|
|
|
FENTANYL 100 MCG/HR TRANSDERMAL PATCH [27908]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
NDC 00406910076
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.57 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.65
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: University Health Alliance Commercial |
$77.99
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 50742054905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 00406911276
|
|
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: MDX Hawaii PPO |
$49.47
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 00378911998
|
|
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: MDX Hawaii PPO |
$49.47
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 00406911276
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 50742054905
|
|
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: MDX Hawaii PPO |
$49.47
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 00378911998
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
NDC 00378911916
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.01 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [41382]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
NDC 00378911916
|
|
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: MDX Hawaii PPO |
$49.47
|
|
