|
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
|
|
|
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 |
$1,767.00 |
| Max. Negotiated Rate |
$5,529.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,850.00
|
| Rate for Payer: AlohaCare Medicare |
$1,767.00
|
| Rate for Payer: Cash Price |
$3,420.00
|
| Rate for Payer: Devoted Health Medicare |
$1,938.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,767.00
|
| 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 |
$1,767.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,130.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,907.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,767.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,529.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,767.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,767.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,767.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,192.00
|
|
|
FOOT PROCEDURES WITH CC
|
Facility
|
IP
|
$23,227.96
|
|
|
Service Code
|
MSDRG 504
|
| Min. Negotiated Rate |
$23,227.96 |
| Max. Negotiated Rate |
$23,227.96 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,227.96
|
|
|
FOOT PROCEDURES WITH MCC
|
Facility
|
IP
|
$23,227.96
|
|
|
Service Code
|
MSDRG 503
|
| Min. Negotiated Rate |
$23,227.96 |
| Max. Negotiated Rate |
$23,227.96 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,227.96
|
|
|
FOOT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$23,227.96
|
|
|
Service Code
|
MSDRG 505
|
| Min. Negotiated Rate |
$23,227.96 |
| Max. Negotiated Rate |
$23,227.96 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,227.96
|
|
|
FORCEPS JEWEL BIPOLAR 20-1060
|
Facility
|
OP
|
$206.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.86 |
| Max. Negotiated Rate |
$199.82 |
| Rate for Payer: AlohaCare Medicaid |
$103.00
|
| Rate for Payer: AlohaCare Medicare |
$63.86
|
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Devoted Health Medicare |
$70.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$195.70
|
| Rate for Payer: Health Management Network Commercial |
$175.10
|
| Rate for Payer: Humana Medicare |
$63.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$185.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.86
|
| Rate for Payer: MDX Hawaii PPO |
$199.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.86
|
| Rate for Payer: University Health Alliance Commercial |
$150.15
|
|
|
FORCEPS JEWEL BIPOLAR 20-1060
|
Facility
|
IP
|
$206.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$175.10 |
| Max. Negotiated Rate |
$199.82 |
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Health Management Network Commercial |
$175.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$185.40
|
| Rate for Payer: MDX Hawaii PPO |
$199.82
|
|
|
FOSAPREPITANT 150 MG IN 250 ML NS IVPB-CNR (SIMPLE) [4080025]
|
Facility
|
IP
|
$1,127.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$957.95 |
| Max. Negotiated Rate |
$1,093.19 |
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: Health Management Network Commercial |
$957.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,014.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,093.19
|
|
|
FOSAPREPITANT 150 MG IN 250 ML NS IVPB-CNR (SIMPLE) [4080025]
|
Facility
|
OP
|
$1,127.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$1,093.19 |
| Rate for Payer: AlohaCare Medicaid |
$563.50
|
| Rate for Payer: AlohaCare Medicare |
$349.37
|
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: Cash Price |
$676.20
|
| Rate for Payer: Devoted Health Medicare |
$383.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$349.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,070.65
|
| Rate for Payer: Health Management Network Commercial |
$957.95
|
| Rate for Payer: Humana Medicare |
$349.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,014.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$574.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$349.37
|
| Rate for Payer: MDX Hawaii PPO |
$1,093.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$349.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$349.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$676.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$349.37
|
| Rate for Payer: University Health Alliance Commercial |
$821.47
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
OP
|
$482.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$467.54 |
| Rate for Payer: AlohaCare Medicaid |
$241.00
|
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$39.06
|
| Rate for Payer: AlohaCare Medicare |
$149.42
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Devoted Health Medicare |
$163.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$149.42
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$457.90
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$409.70
|
| Rate for Payer: Humana Medicare |
$39.06
|
| Rate for Payer: Humana Medicare |
$149.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$433.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$245.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$149.42
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$467.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$149.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$149.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$289.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$149.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.06
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$351.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Health Management Network Commercial |
$409.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$433.80
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$467.54
|
|
|
FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL) [430106783]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicaid |
$241.00
|
| Rate for Payer: AlohaCare Medicaid |
$207.50
|
| Rate for Payer: AlohaCare Medicare |
$128.65
|
| Rate for Payer: AlohaCare Medicare |
$39.06
|
| Rate for Payer: AlohaCare Medicare |
$149.42
|
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Devoted Health Medicare |
$163.88
|
| Rate for Payer: Devoted Health Medicare |
$141.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$149.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$128.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$394.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$457.90
|
| Rate for Payer: Health Management Network Commercial |
$409.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$352.75
|
| Rate for Payer: Humana Medicare |
$39.06
|
| Rate for Payer: Humana Medicare |
$128.65
|
| Rate for Payer: Humana Medicare |
$149.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$373.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$433.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$245.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$211.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$149.42
|
| Rate for Payer: MDX Hawaii PPO |
$467.54
|
| Rate for Payer: MDX Hawaii PPO |
$402.55
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$128.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$149.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$128.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$149.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$249.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$289.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$128.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$149.42
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$302.49
|
| Rate for Payer: University Health Alliance Commercial |
$351.33
|
|
|
FOSAPREPITANT DIMEGLUMINE 150 MG/5ML IV (WET SOLR VIAL) [430106783]
|
Facility
|
IP
|
$482.00
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$409.70 |
| Max. Negotiated Rate |
$467.54 |
| Rate for Payer: Cash Price |
$289.20
|
| Rate for Payer: Cash Price |
$249.00
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$409.70
|
| Rate for Payer: Health Management Network Commercial |
$352.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$373.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$433.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$402.55
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$467.54
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
NDC 70700026894
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.85 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
NDC 70700026899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.85 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
NDC 70700026899
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.31 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: AlohaCare Medicaid |
$100.50
|
| Rate for Payer: AlohaCare Medicare |
$62.31
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Devoted Health Medicare |
$68.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.95
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Humana Medicare |
$62.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.31
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.31
|
| Rate for Payer: University Health Alliance Commercial |
$146.51
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
NDC 69097057967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.85 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
NDC 69097057967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.31 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: AlohaCare Medicaid |
$100.50
|
| Rate for Payer: AlohaCare Medicare |
$62.31
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Devoted Health Medicare |
$68.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.95
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Humana Medicare |
$62.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.31
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.31
|
| Rate for Payer: University Health Alliance Commercial |
$146.51
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
NDC 70700026894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.31 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: AlohaCare Medicaid |
$100.50
|
| Rate for Payer: AlohaCare Medicare |
$62.31
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Devoted Health Medicare |
$68.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.95
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Humana Medicare |
$62.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.31
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.31
|
| Rate for Payer: University Health Alliance Commercial |
$146.51
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
NDC 00069600125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.70 |
| Max. Negotiated Rate |
$118.34 |
| Rate for Payer: Cash Price |
$73.20
|
| Rate for Payer: Cash Price |
$156.60
|
| Rate for Payer: Health Management Network Commercial |
$221.85
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.90
|
| Rate for Payer: MDX Hawaii PPO |
$118.34
|
| Rate for Payer: MDX Hawaii PPO |
$253.17
|
|
|
FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION [88011]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 63323040302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 68462062264
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.00
|
| Rate for Payer: MDX Hawaii PPO |
$194.00
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
NDC 68462062210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.00 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: Cash Price |
$120.00
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.00
|
| Rate for Payer: MDX Hawaii PPO |
$194.00
|
|
|
FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION [88010]
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
NDC 00069600121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$309.40 |
| Max. Negotiated Rate |
$353.08 |
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$309.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.60
|
| Rate for Payer: MDX Hawaii PPO |
$353.08
|
|
