|
FENTANYL 75 MCG/HR TRANSDERMAL PATCH [27907]
|
Facility
|
OP
|
$101.00
|
|
|
Service Code
|
NDC 00378912316
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.50 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: AlohaCare Medicaid |
$50.50
|
| Rate for Payer: AlohaCare Medicare |
$76.76
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Devoted Health Medicare |
$84.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.95
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Humana Medicare |
$76.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.76
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.76
|
| Rate for Payer: University Health Alliance Commercial |
$73.62
|
|
|
FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN (WRAPPED) [4080003037]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$9.12
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$10.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$9.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.12
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN (WRAPPED) [4080003037]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [134120]
|
Facility
|
OP
|
$1,651.00
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$1,601.47 |
| Rate for Payer: AlohaCare Medicaid |
$825.50
|
| Rate for Payer: AlohaCare Medicaid |
$50.50
|
| Rate for Payer: AlohaCare Medicare |
$76.76
|
| Rate for Payer: AlohaCare Medicare |
$1,254.76
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$990.60
|
| Rate for Payer: Cash Price |
$990.60
|
| Rate for Payer: Devoted Health Medicare |
$84.84
|
| Rate for Payer: Devoted Health Medicare |
$1,386.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,254.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,568.45
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Health Management Network Commercial |
$1,403.35
|
| Rate for Payer: Humana Medicare |
$76.76
|
| Rate for Payer: Humana Medicare |
$1,254.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,485.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$842.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,254.76
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
| Rate for Payer: MDX Hawaii PPO |
$1,601.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,254.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,254.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$60.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$990.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,254.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.76
|
| Rate for Payer: University Health Alliance Commercial |
$73.62
|
| Rate for Payer: University Health Alliance Commercial |
$1,203.41
|
|
|
FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS [134120]
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$990.60
|
| Rate for Payer: Health Management Network Commercial |
$1,403.35
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,485.90
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
| Rate for Payer: MDX Hawaii PPO |
$1,601.47
|
|
|
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION [134136]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
NDC 70092110436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION - BOLUS FROM BAG [4080509]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
NDC 70092110436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
FENTANYL (PF) 2 MCG/ML-BUPIVACAINE 0.125 %-NACL INJECTION SOLUTION - INFUSION ONLY [4080508]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
NDC 70092110436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [131632]
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicaid |
$52.50
|
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: AlohaCare Medicare |
$100.32
|
| Rate for Payer: AlohaCare Medicare |
$7.60
|
| Rate for Payer: AlohaCare Medicare |
$79.80
|
| Rate for Payer: AlohaCare Medicare |
$9.12
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$110.88
|
| Rate for Payer: Devoted Health Medicare |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$10.08
|
| Rate for Payer: Devoted Health Medicare |
$88.20
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$79.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$99.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$79.80
|
| Rate for Payer: Humana Medicare |
$7.60
|
| Rate for Payer: Humana Medicare |
$9.12
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Humana Medicare |
$100.32
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$79.80
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$79.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$79.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$79.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$79.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.32
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
| Rate for Payer: University Health Alliance Commercial |
$76.53
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION [131632]
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS J3010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$89.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$94.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$101.85
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
FERIC QUICK STAT V16-0397
|
Facility
|
OP
|
$177.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$88.50 |
| Max. Negotiated Rate |
$171.69 |
| Rate for Payer: AlohaCare Medicaid |
$88.50
|
| Rate for Payer: AlohaCare Medicare |
$134.52
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Devoted Health Medicare |
$148.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$134.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$168.15
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: Humana Medicare |
$134.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$134.52
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$134.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$134.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$134.52
|
| Rate for Payer: University Health Alliance Commercial |
$129.02
|
|
|
FERIC QUICK STAT V16-0397
|
Facility
|
IP
|
$177.00
|
|
|
Hospital Revenue Code
|
272
|
| 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: Kaiser Permanente Commercial |
$159.30
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
|
|
FERMORAL HEAD 3.5 X 28MM
|
Facility
|
IP
|
$1,853.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.68 |
| Max. Negotiated Rate |
$1,797.41 |
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,297.10
|
| Rate for Payer: Health Management Network Commercial |
$1,575.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,667.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,797.41
|
| Rate for Payer: University Health Alliance Commercial |
$1,037.68
|
|
|
FERMORAL HEAD 3.5 X 28MM
|
Facility
|
OP
|
$1,853.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.50 |
| Max. Negotiated Rate |
$1,797.41 |
| Rate for Payer: AlohaCare Medicaid |
$926.50
|
| Rate for Payer: AlohaCare Medicare |
$1,408.28
|
| Rate for Payer: Cash Price |
$1,111.80
|
| Rate for Payer: Devoted Health Medicare |
$1,556.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,408.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,297.10
|
| Rate for Payer: Health Management Network Commercial |
$1,575.05
|
| Rate for Payer: Humana Medicare |
$1,408.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,667.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$945.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,408.28
|
| Rate for Payer: MDX Hawaii PPO |
$1,797.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,408.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,408.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,408.28
|
| Rate for Payer: University Health Alliance Commercial |
$1,037.68
|
|
|
FERMORAL HEAD CERAMIC 18-3675
|
Facility
|
OP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,338.00 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,338.00
|
| Rate for Payer: AlohaCare Medicare |
$2,033.76
|
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Devoted Health Medicare |
$2,247.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,033.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Humana Medicare |
$2,033.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,364.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,033.76
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,033.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,033.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,033.76
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
FERMORAL HEAD CERAMIC 18-3675
|
Facility
|
IP
|
$2,676.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,498.56 |
| Max. Negotiated Rate |
$2,595.72 |
| Rate for Payer: Cash Price |
$1,605.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,873.20
|
| Rate for Payer: Health Management Network Commercial |
$2,274.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,408.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,595.72
|
| Rate for Payer: University Health Alliance Commercial |
$1,498.56
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [122648]
|
Facility
|
IP
|
$2,900.00
|
|
|
Service Code
|
HCPCS J1439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,465.00 |
| Max. Negotiated Rate |
$2,813.00 |
| Rate for Payer: Cash Price |
$1,740.00
|
| Rate for Payer: Health Management Network Commercial |
$2,465.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,610.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,813.00
|
|
|
FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION [122648]
|
Facility
|
OP
|
$2,900.00
|
|
|
Service Code
|
HCPCS J1439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2,813.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,450.00
|
| Rate for Payer: AlohaCare Medicare |
$2,204.00
|
| Rate for Payer: Cash Price |
$1,740.00
|
| Rate for Payer: Cash Price |
$1,740.00
|
| Rate for Payer: Devoted Health Medicare |
$2,436.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.14
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,204.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,755.00
|
| Rate for Payer: Health Management Network Commercial |
$2,465.00
|
| Rate for Payer: Humana Medicare |
$2,204.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,610.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,479.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,204.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,813.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,204.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,204.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,740.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,204.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,113.81
|
|
|
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 74805000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$10.64
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$11.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$10.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.64
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.64
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 74805000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 01150000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS [95693]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 01150000000
|
|
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: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 53005000000
|
|
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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 53005000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID [194491]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00559000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
