|
FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION [137870]
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
250
|
| 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: MDX Hawaii PPO |
$145.50
|
|
|
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION [82204]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION [82204]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.40
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.20
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
|
|
FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [82180]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION [82200]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
250
|
| 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: MDX Hawaii PPO |
$14.55
|
|
|
FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION [82200]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]
|
Facility
|
IP
|
$124.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Health Management Network Commercial |
$105.40
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
| Rate for Payer: MDX Hawaii PPO |
$120.28
|
|
|
FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION [98249]
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS J9190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$59.40
|
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$117.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.05
|
| Rate for Payer: Health Management Network Commercial |
$84.15
|
| Rate for Payer: Health Management Network Commercial |
$105.40
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$96.03
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$120.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$74.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.40
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
| Rate for Payer: University Health Alliance Commercial |
$90.38
|
| Rate for Payer: University Health Alliance Commercial |
$72.16
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 68001039900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904734561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904734561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
FLUOXETINE 10 MG CAPSULE [10069]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 68001039900
|
|
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: MDX Hawaii PPO |
$9.70
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
NDC 00832603212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.27 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$168.15
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.27
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
| Rate for Payer: University Health Alliance Commercial |
$129.02
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
NDC 54838052340
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.27 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$168.15
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.27
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
| Rate for Payer: University Health Alliance Commercial |
$129.02
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
NDC 00121072104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.45 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
NDC 00121072104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.27 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$168.15
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.27
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
| Rate for Payer: University Health Alliance Commercial |
$129.02
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
NDC 00832603212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.45 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
|
|
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION [38488]
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
NDC 54838052340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.45 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904734661
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
FLUOXETINE 20 MG CAPSULE [10070]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904734661
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
FLUPHENAZINE 5 MG TABLET [3221]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 69238168001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
FLUPHENAZINE 5 MG TABLET [3221]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 69238168001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
FLUPHENAZINE 5 MG TABLET [3221]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687074901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
FLUPHENAZINE 5 MG TABLET [3221]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687074911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
