|
FLUVOXAMINE 50 MG TABLET [10085]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 62559015901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
FLX OPTN FEM #00-5964-014-52
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,800.00 |
| Max. Negotiated Rate |
$4,850.00 |
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,500.00
|
| Rate for Payer: Health Management Network Commercial |
$4,250.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,500.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,850.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,800.00
|
|
|
FLX OPTN FEM #00-5964-014-52
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,500.00 |
| Max. Negotiated Rate |
$4,850.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,500.00
|
| Rate for Payer: AlohaCare Medicare |
$3,800.00
|
| Rate for Payer: Cash Price |
$3,000.00
|
| Rate for Payer: Devoted Health Medicare |
$4,200.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,800.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,500.00
|
| Rate for Payer: Health Management Network Commercial |
$4,250.00
|
| Rate for Payer: Humana Medicare |
$3,800.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,500.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,550.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,800.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,850.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,800.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,800.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,800.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,800.00
|
|
|
FOGARTY DBL SAFEJAW INSERT 33M
|
Facility
|
OP
|
$90.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$87.30 |
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$68.40
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$75.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$68.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.40
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
FOGARTY DBL SAFEJAW INSERT 33M
|
Facility
|
IP
|
$90.00
|
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
FOGARTY DBL SAFEJAW INSERT SE
|
Facility
|
OP
|
$111.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.50 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: AlohaCare Medicaid |
$55.50
|
| Rate for Payer: AlohaCare Medicare |
$84.36
|
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Devoted Health Medicare |
$93.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.45
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Humana Medicare |
$84.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.36
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.36
|
| Rate for Payer: University Health Alliance Commercial |
$80.91
|
|
|
FOGARTY DBL SAFEJAW INSERT SE
|
Facility
|
IP
|
$111.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$94.35 |
| Max. Negotiated Rate |
$107.67 |
| Rate for Payer: Cash Price |
$66.60
|
| Rate for Payer: Health Management Network Commercial |
$94.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.90
|
| Rate for Payer: MDX Hawaii PPO |
$107.67
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 69315012701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687068111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687068101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 69315012701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687068111
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
FOLIC ACID 1 MG TABLET [3233]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687068101
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [3232]
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS J1808
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.90 |
| Max. Negotiated Rate |
$149.38 |
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$196.35
|
| Rate for Payer: Health Management Network Commercial |
$130.90
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$207.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$149.38
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: MDX Hawaii PPO |
$224.07
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [22185]
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS J1451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,955.00 |
| Max. Negotiated Rate |
$2,231.00 |
| Rate for Payer: Cash Price |
$1,380.00
|
| Rate for Payer: Cash Price |
$1,546.80
|
| Rate for Payer: Health Management Network Commercial |
$2,191.30
|
| Rate for Payer: Health Management Network Commercial |
$1,955.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,070.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,320.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,231.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,500.66
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.35 |
| Max. Negotiated Rate |
$127.07 |
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.90
|
| Rate for Payer: MDX Hawaii PPO |
$127.07
|
|
|
FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE [108029]
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$127.07 |
| Rate for Payer: AlohaCare Medicaid |
$65.50
|
| Rate for Payer: AlohaCare Medicare |
$99.56
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Devoted Health Medicare |
$110.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$99.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$124.45
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Humana Medicare |
$99.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.56
|
| Rate for Payer: MDX Hawaii PPO |
$127.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$78.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$99.56
|
| Rate for Payer: University Health Alliance Commercial |
$95.49
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: AlohaCare Medicaid |
$41.00
|
| Rate for Payer: AlohaCare Medicare |
$62.32
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Devoted Health Medicare |
$68.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.90
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Humana Medicare |
$62.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.32
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.32
|
| Rate for Payer: University Health Alliance Commercial |
$59.77
|
|
|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.70 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
|
|
FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE [108027]
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.05 |
| Max. Negotiated Rate |
$187.21 |
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Health Management Network Commercial |
$164.05
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$173.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
| Rate for Payer: MDX Hawaii PPO |
$187.21
|
|
|
FONDAPARINUX 5 MG/0.4 ML SUBCUTANEOUS SOLUTION SYRINGE [108027]
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$187.21 |
| Rate for Payer: AlohaCare Medicaid |
$96.50
|
| Rate for Payer: AlohaCare Medicaid |
$102.00
|
| Rate for Payer: AlohaCare Medicare |
$155.04
|
| Rate for Payer: AlohaCare Medicare |
$146.68
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cash Price |
$115.80
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Devoted Health Medicare |
$162.12
|
| Rate for Payer: Devoted Health Medicare |
$171.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$146.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$183.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$193.80
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Health Management Network Commercial |
$164.05
|
| Rate for Payer: Humana Medicare |
$146.68
|
| Rate for Payer: Humana Medicare |
$155.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$173.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$146.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.04
|
| Rate for Payer: MDX Hawaii PPO |
$187.21
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$146.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$146.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$122.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$115.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$146.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.04
|
| Rate for Payer: University Health Alliance Commercial |
$140.68
|
| Rate for Payer: University Health Alliance Commercial |
$148.70
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
IP
|
$131.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.35 |
| Max. Negotiated Rate |
$127.07 |
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
| Rate for Payer: MDX Hawaii PPO |
$127.07
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
|
OP
|
$131.00
|
|
|
Service Code
|
HCPCS J1652
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$127.07 |
| Rate for Payer: AlohaCare Medicaid |
$65.50
|
| Rate for Payer: AlohaCare Medicaid |
$102.00
|
| Rate for Payer: AlohaCare Medicare |
$155.04
|
| Rate for Payer: AlohaCare Medicare |
$99.56
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$78.60
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Devoted Health Medicare |
$110.04
|
| Rate for Payer: Devoted Health Medicare |
$171.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$99.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$124.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$193.80
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Health Management Network Commercial |
$111.35
|
| Rate for Payer: Humana Medicare |
$99.56
|
| Rate for Payer: Humana Medicare |
$155.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$117.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$66.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$99.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.04
|
| Rate for Payer: MDX Hawaii PPO |
$127.07
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$99.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$122.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$78.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$99.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.04
|
| Rate for Payer: University Health Alliance Commercial |
$95.49
|
| Rate for Payer: University Health Alliance Commercial |
$148.70
|
|
|
FOOT
|
Facility
|
IP
|
$5,700.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,192.00 |
| Max. Negotiated Rate |
$5,529.00 |
| Rate for Payer: Cash Price |
$3,420.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,990.00
|
| Rate for Payer: Health Management Network Commercial |
$4,845.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,130.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,529.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,192.00
|
|
|
FOOT
|
Facility
|
OP
|
$5,700.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,850.00 |
| Max. Negotiated Rate |
$5,529.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,850.00
|
| Rate for Payer: AlohaCare Medicare |
$4,332.00
|
| Rate for Payer: Cash Price |
$3,420.00
|
| Rate for Payer: Devoted Health Medicare |
$4,788.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,332.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,990.00
|
| Rate for Payer: Health Management Network Commercial |
$4,845.00
|
| Rate for Payer: Humana Medicare |
$4,332.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,130.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,907.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,332.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,529.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,332.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,332.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,332.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,192.00
|
|
