|
FRN RT 9X340MM 04.033.964S
|
Facility
|
IP
|
$5,002.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,801.12 |
| Max. Negotiated Rate |
$4,851.94 |
| Rate for Payer: Cash Price |
$3,001.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,501.40
|
| Rate for Payer: Health Management Network Commercial |
$4,251.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,501.80
|
| Rate for Payer: MDX Hawaii PPO |
$4,851.94
|
| Rate for Payer: University Health Alliance Commercial |
$2,801.12
|
|
|
FULL CURVE A/V ACCESS TUNNELER
|
Facility
|
OP
|
$257.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$128.50 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: AlohaCare Medicaid |
$128.50
|
| Rate for Payer: AlohaCare Medicare |
$195.32
|
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Devoted Health Medicare |
$215.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$195.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$244.15
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Humana Medicare |
$195.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$131.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$195.32
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$195.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$195.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$195.32
|
| Rate for Payer: University Health Alliance Commercial |
$187.33
|
|
|
FULL CURVE A/V ACCESS TUNNELER
|
Facility
|
IP
|
$257.00
|
|
|
Service Code
|
HCPCS C1894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$218.45 |
| Max. Negotiated Rate |
$249.29 |
| Rate for Payer: Cash Price |
$154.20
|
| Rate for Payer: Health Management Network Commercial |
$218.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$231.30
|
| Rate for Payer: MDX Hawaii PPO |
$249.29
|
|
|
FULL TERM NEONATE WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$18,985.30
|
|
|
Service Code
|
MSDRG 793
|
| Min. Negotiated Rate |
$18,985.30 |
| Max. Negotiated Rate |
$18,985.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18,985.30
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [187815]
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS J9395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicaid |
$150.00
|
| Rate for Payer: AlohaCare Medicare |
$228.00
|
| Rate for Payer: AlohaCare Medicare |
$114.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Devoted Health Medicare |
$126.00
|
| Rate for Payer: Devoted Health Medicare |
$252.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$228.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$285.00
|
| Rate for Payer: Health Management Network Commercial |
$255.00
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$228.00
|
| Rate for Payer: Humana Medicare |
$114.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$270.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$153.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$228.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: MDX Hawaii PPO |
$291.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$228.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$228.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$180.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$90.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$228.00
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
| Rate for Payer: University Health Alliance Commercial |
$218.67
|
|
|
FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE [187815]
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS J9395
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Health Management Network Commercial |
$255.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$270.00
|
| Rate for Payer: MDX Hawaii PPO |
$291.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1938
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
FUROSEMIDE 10 MG/ML INJECTION SOLUTION [3291]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J1938
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$9.88
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: AlohaCare Medicare |
$9.12
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$8.36
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$10.08
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$10.92
|
| Rate for Payer: Devoted Health Medicare |
$9.24
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$9.12
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Humana Medicare |
$8.36
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Humana Medicare |
$9.88
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 00054329450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 00054329446
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.00 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$21.28
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$23.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$21.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.28
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.28
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 00054329450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: AlohaCare Medicaid |
$22.50
|
| Rate for Payer: AlohaCare Medicare |
$34.20
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Devoted Health Medicare |
$37.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.75
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Humana Medicare |
$34.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.20
|
| Rate for Payer: University Health Alliance Commercial |
$32.80
|
|
|
FUROSEMIDE 10 MG/ML ORAL SOLUTION [3292]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00054329446
|
|
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: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
FUROSEMIDE 20 MG TABLET [3294]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904717761
|
|
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
|
|
|
FUROSEMIDE 20 MG TABLET [3294]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904717761
|
|
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
|
|
|
FUROSEMIDE 40 MG TABLET [3295]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904717861
|
|
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
|
|
|
FUROSEMIDE 40 MG TABLET [3295]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904717861
|
|
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
|
|
|
FUROSEMIDE 40 MG TABLET [3295]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 69315011701
|
|
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
|
|
|
FUROSEMIDE 40 MG TABLET [3295]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 69315011701
|
|
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
|
|
|
FUROSEMIDE 80 MG TABLET [3296]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00054830125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
FUROSEMIDE 80 MG TABLET [3296]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 69315011801
|
|
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
|
|
|
FUROSEMIDE 80 MG TABLET [3296]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 69315011801
|
|
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
|
|
|
FUROSEMIDE 80 MG TABLET [3296]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00054830125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
FUROSEMIDE TABLETS (LASIX) 20 MG (TAKE HOME) [4080362]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080150
|
|
Hospital Revenue Code
|
253
|
| 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
|
|
|
FUROSEMIDE TABLETS (LASIX) 20 MG (TAKE HOME) [4080362]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080150
|
|
Hospital Revenue Code
|
253
|
| 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
|
|
|
FUSION CUP 10 HOLE 18MM FC10
|
Facility
|
IP
|
$2,780.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.80 |
| Max. Negotiated Rate |
$2,696.60 |
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,946.00
|
| Rate for Payer: Health Management Network Commercial |
$2,363.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,502.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,696.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,556.80
|
|
