|
CLSTR SHEL 64OO 00-8757-064-01
|
Facility
|
OP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,364.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,200.00
|
| Rate for Payer: AlohaCare Medicare |
$1,364.00
|
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Devoted Health Medicare |
$1,496.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,364.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,080.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Humana Medicare |
$1,364.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,960.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,244.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,364.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,364.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,364.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,364.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,464.00
|
|
|
CLSTR SHEL 64OO 00-8757-064-01
|
Facility
|
IP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: Cash Price |
$2,640.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,080.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,960.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,464.00
|
|
|
CMC MINI TIGHTROPE IMPLANT SYS
|
Facility
|
OP
|
$2,819.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$873.89 |
| Max. Negotiated Rate |
$2,734.43 |
| Rate for Payer: AlohaCare Medicaid |
$1,409.50
|
| Rate for Payer: AlohaCare Medicare |
$873.89
|
| Rate for Payer: Cash Price |
$1,691.40
|
| Rate for Payer: Devoted Health Medicare |
$958.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$873.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,973.30
|
| Rate for Payer: Health Management Network Commercial |
$2,396.15
|
| Rate for Payer: Humana Medicare |
$873.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,537.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,437.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$873.89
|
| Rate for Payer: MDX Hawaii PPO |
$2,734.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$873.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$873.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$873.89
|
| Rate for Payer: University Health Alliance Commercial |
$1,578.64
|
|
|
CMC MINI TIGHTROPE IMPLANT SYS
|
Facility
|
IP
|
$2,819.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,578.64 |
| Max. Negotiated Rate |
$2,734.43 |
| Rate for Payer: Cash Price |
$1,691.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,973.30
|
| Rate for Payer: Health Management Network Commercial |
$2,396.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,537.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,734.43
|
| Rate for Payer: University Health Alliance Commercial |
$1,578.64
|
|
|
C/M HUMERAL 4" 32-8105-025-04
|
Facility
|
IP
|
$10,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,048.00 |
| Max. Negotiated Rate |
$10,476.00 |
| Rate for Payer: Cash Price |
$6,480.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,560.00
|
| Rate for Payer: Health Management Network Commercial |
$9,180.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,720.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,476.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,048.00
|
|
|
C/M HUMERAL 4" 32-8105-025-04
|
Facility
|
OP
|
$10,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,348.00 |
| Max. Negotiated Rate |
$10,476.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,400.00
|
| Rate for Payer: AlohaCare Medicare |
$3,348.00
|
| Rate for Payer: Cash Price |
$6,480.00
|
| Rate for Payer: Devoted Health Medicare |
$3,672.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,348.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,560.00
|
| Rate for Payer: Health Management Network Commercial |
$9,180.00
|
| Rate for Payer: Humana Medicare |
$3,348.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,720.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,508.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,348.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,476.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,348.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,348.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,348.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,048.00
|
|
|
C/M ULNA 3" 32-8105-043-01
|
Facility
|
OP
|
$9,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,038.00 |
| Max. Negotiated Rate |
$9,506.00 |
| Rate for Payer: AlohaCare Medicaid |
$4,900.00
|
| Rate for Payer: AlohaCare Medicare |
$3,038.00
|
| Rate for Payer: Cash Price |
$5,880.00
|
| Rate for Payer: Devoted Health Medicare |
$3,332.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,038.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,860.00
|
| Rate for Payer: Health Management Network Commercial |
$8,330.00
|
| Rate for Payer: Humana Medicare |
$3,038.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,820.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,998.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,038.00
|
| Rate for Payer: MDX Hawaii PPO |
$9,506.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,038.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,038.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,038.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,488.00
|
|
|
C/M ULNA 3" 32-8105-043-01
|
Facility
|
IP
|
$9,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,488.00 |
| Max. Negotiated Rate |
$9,506.00 |
| Rate for Payer: Cash Price |
$5,880.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,860.00
|
| Rate for Payer: Health Management Network Commercial |
$8,330.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8,820.00
|
| Rate for Payer: MDX Hawaii PPO |
$9,506.00
|
| Rate for Payer: University Health Alliance Commercial |
$5,488.00
|
|
|
COAGULATION DISORDERS
|
Facility
|
IP
|
$32,258.42
|
|
|
Service Code
|
MSDRG 813
|
| Min. Negotiated Rate |
$32,258.42 |
| Max. Negotiated Rate |
$32,258.42 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$32,258.42
|
|
|
COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [134078]
|
Facility
|
IP
|
$2,779.00
|
|
|
Service Code
|
HCPCS J7195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,362.15 |
| Max. Negotiated Rate |
$2,695.63 |
| Rate for Payer: Cash Price |
$1,667.40
|
| Rate for Payer: Health Management Network Commercial |
$2,362.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,501.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,695.63
|
|
|
COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION [134078]
|
Facility
|
OP
|
$2,779.00
|
|
|
Service Code
|
HCPCS J7195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$2,695.63 |
| Rate for Payer: AlohaCare Medicaid |
$1,389.50
|
| Rate for Payer: AlohaCare Medicare |
$861.49
|
| Rate for Payer: Cash Price |
$1,667.40
|
| Rate for Payer: Cash Price |
$1,667.40
|
| Rate for Payer: Devoted Health Medicare |
$944.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$861.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,640.05
|
| Rate for Payer: Health Management Network Commercial |
$2,362.15
|
| Rate for Payer: Humana Medicare |
$861.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,501.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,417.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$861.49
|
| Rate for Payer: MDX Hawaii PPO |
$2,695.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$861.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$861.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,667.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$861.49
|
| Rate for Payer: University Health Alliance Commercial |
$2,025.61
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [134080]
|
Facility
|
IP
|
$6,875.00
|
|
|
Service Code
|
HCPCS J7195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,843.75 |
| Max. Negotiated Rate |
$6,668.75 |
| Rate for Payer: Cash Price |
$4,125.00
|
| Rate for Payer: Health Management Network Commercial |
$5,843.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,187.50
|
| Rate for Payer: MDX Hawaii PPO |
$6,668.75
|
|
|
COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION [134080]
|
Facility
|
OP
|
$6,875.00
|
|
|
Service Code
|
HCPCS J7195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$6,668.75 |
| Rate for Payer: AlohaCare Medicaid |
$3,437.50
|
| Rate for Payer: AlohaCare Medicare |
$2,131.25
|
| Rate for Payer: Cash Price |
$4,125.00
|
| Rate for Payer: Cash Price |
$4,125.00
|
| Rate for Payer: Devoted Health Medicare |
$2,337.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,131.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,531.25
|
| Rate for Payer: Health Management Network Commercial |
$5,843.75
|
| Rate for Payer: Humana Medicare |
$2,131.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,187.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,506.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,131.25
|
| Rate for Payer: MDX Hawaii PPO |
$6,668.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,131.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,131.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,125.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,131.25
|
| Rate for Payer: University Health Alliance Commercial |
$5,011.19
|
|
|
COAL TAR 0.5 % SHAMPOO [27670]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 00904525944
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$6.82
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$7.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$6.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.82
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.82
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
COAL TAR 0.5 % SHAMPOO [27670]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 00904525944
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00121177500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00121177500
|
|
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
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00121177505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00121177540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00121177540
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID [78003]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00121177505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00527169801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
CODEINE SULFATE 30 MG TABLET [1802]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00527169801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 60687072711
|
|
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
|
|
|
COLCHICINE 0.6 MG TABLET [1821]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 50268018715
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$6.82
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$7.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$6.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.82
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.82
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
