|
LEVOTHYROXINE 25 MCG TABLET [4420]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687045311
|
|
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
|
|
|
LEVOTHYROXINE 25 MCG TABLET [4420]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687045301
|
|
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
|
|
|
LEVOTHYROXINE 50 MCG TABLET [4421]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079044020
|
|
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
|
|
|
LEVOTHYROXINE 50 MCG TABLET [4421]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687046411
|
|
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
|
|
|
LEVOTHYROXINE 50 MCG TABLET [4421]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687046401
|
|
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
|
|
|
LEVOTHYROXINE 50 MCG TABLET [4421]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079044020
|
|
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
|
|
|
LEVOTHYROXINE 50 MCG TABLET [4421]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687046401
|
|
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
|
|
|
LEVOTHYROXINE 50 MCG TABLET [4421]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687046411
|
|
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
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687047511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687047501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687047511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00527328246
|
|
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
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687047501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079044120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079044120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 75 MCG TABLET [4422]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00527328246
|
|
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
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687048601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 42292003820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 42292003820
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687048611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687048601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LEVOTHYROXINE 88 MCG TABLET [10403]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687048611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
LFIT V40 FEMORAL HD 6260-9-128
|
Facility
|
OP
|
$1,971.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$985.50 |
| Max. Negotiated Rate |
$1,911.87 |
| Rate for Payer: AlohaCare Medicaid |
$985.50
|
| Rate for Payer: AlohaCare Medicare |
$1,497.96
|
| Rate for Payer: Cash Price |
$1,182.60
|
| Rate for Payer: Devoted Health Medicare |
$1,655.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,497.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,379.70
|
| Rate for Payer: Health Management Network Commercial |
$1,675.35
|
| Rate for Payer: Humana Medicare |
$1,497.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,773.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,005.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,497.96
|
| Rate for Payer: MDX Hawaii PPO |
$1,911.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,497.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,497.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,497.96
|
| Rate for Payer: University Health Alliance Commercial |
$1,103.76
|
|
|
LFIT V40 FEMORAL HD 6260-9-128
|
Facility
|
IP
|
$1,971.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,103.76 |
| Max. Negotiated Rate |
$1,911.87 |
| Rate for Payer: Cash Price |
$1,182.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,379.70
|
| Rate for Payer: Health Management Network Commercial |
$1,675.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,773.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,911.87
|
| Rate for Payer: University Health Alliance Commercial |
$1,103.76
|
|
|
LFITV40 FH 22.2MM 6260-9-122
|
Facility
|
IP
|
$1,990.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,114.40 |
| Max. Negotiated Rate |
$1,930.30 |
| Rate for Payer: Cash Price |
$1,194.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,393.00
|
| Rate for Payer: Health Management Network Commercial |
$1,691.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,791.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,930.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,114.40
|
|
