|
MODULE TL STERILE 99-54-24100
|
Facility
|
IP
|
$1,400.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,190.00 |
| Max. Negotiated Rate |
$1,358.00 |
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Health Management Network Commercial |
$1,190.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,260.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,358.00
|
|
|
MOLD CEMT HIP HEAD 60MM 431184
|
Facility
|
IP
|
$3,770.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,111.20 |
| Max. Negotiated Rate |
$3,656.90 |
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,639.00
|
| Rate for Payer: Health Management Network Commercial |
$3,204.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,393.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,656.90
|
| Rate for Payer: University Health Alliance Commercial |
$2,111.20
|
|
|
MOLD CEMT HIP HEAD 60MM 431184
|
Facility
|
OP
|
$3,770.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,168.70 |
| Max. Negotiated Rate |
$3,656.90 |
| Rate for Payer: AlohaCare Medicaid |
$1,885.00
|
| Rate for Payer: AlohaCare Medicare |
$1,168.70
|
| Rate for Payer: Cash Price |
$2,262.00
|
| Rate for Payer: Devoted Health Medicare |
$1,281.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,168.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,639.00
|
| Rate for Payer: Health Management Network Commercial |
$3,204.50
|
| Rate for Payer: Humana Medicare |
$1,168.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,393.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,922.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,168.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,656.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,168.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,168.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,168.70
|
| Rate for Payer: University Health Alliance Commercial |
$2,111.20
|
|
|
MOLD HIP STEM 11X200 431196
|
Facility
|
OP
|
$4,720.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,463.20 |
| Max. Negotiated Rate |
$4,578.40 |
| Rate for Payer: AlohaCare Medicaid |
$2,360.00
|
| Rate for Payer: AlohaCare Medicare |
$1,463.20
|
| Rate for Payer: Cash Price |
$2,832.00
|
| Rate for Payer: Devoted Health Medicare |
$1,604.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,463.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,304.00
|
| Rate for Payer: Health Management Network Commercial |
$4,012.00
|
| Rate for Payer: Humana Medicare |
$1,463.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,248.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,407.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,463.20
|
| Rate for Payer: MDX Hawaii PPO |
$4,578.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,463.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,463.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,463.20
|
| Rate for Payer: University Health Alliance Commercial |
$2,643.20
|
|
|
MOLD HIP STEM 11X200 431196
|
Facility
|
IP
|
$4,720.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.20 |
| Max. Negotiated Rate |
$4,578.40 |
| Rate for Payer: Cash Price |
$2,832.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,304.00
|
| Rate for Payer: Health Management Network Commercial |
$4,012.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,248.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,578.40
|
| Rate for Payer: University Health Alliance Commercial |
$2,643.20
|
|
|
MOMENTUM CRT-D IS-1/DF
|
Facility
|
OP
|
$34,290.00
|
|
|
Service Code
|
HCPCS C1882
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$10,629.90 |
| Max. Negotiated Rate |
$33,261.30 |
| Rate for Payer: AlohaCare Medicaid |
$17,145.00
|
| Rate for Payer: AlohaCare Medicare |
$10,629.90
|
| Rate for Payer: Cash Price |
$20,574.00
|
| Rate for Payer: Devoted Health Medicare |
$11,658.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,629.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24,003.00
|
| Rate for Payer: Health Management Network Commercial |
$29,146.50
|
| Rate for Payer: Humana Medicare |
$10,629.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,861.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17,487.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,629.90
|
| Rate for Payer: MDX Hawaii PPO |
$33,261.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,629.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,629.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,629.90
|
| Rate for Payer: University Health Alliance Commercial |
$19,202.40
|
|
|
MOMENTUM CRT-D IS-1/DF
|
Facility
|
IP
|
$34,290.00
|
|
|
Service Code
|
HCPCS C1882
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$19,202.40 |
| Max. Negotiated Rate |
$33,261.30 |
| Rate for Payer: Cash Price |
$20,574.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24,003.00
|
| Rate for Payer: Health Management Network Commercial |
$29,146.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,861.00
|
| Rate for Payer: MDX Hawaii PPO |
$33,261.30
|
| Rate for Payer: University Health Alliance Commercial |
$19,202.40
|
|
|
MOMENTUM EL ICD R
|
Facility
|
OP
|
$29,192.00
|
|
|
Service Code
|
HCPCS C1721
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$9,049.52 |
| Max. Negotiated Rate |
$28,316.24 |
| Rate for Payer: AlohaCare Medicaid |
$14,596.00
|
| Rate for Payer: AlohaCare Medicare |
$9,049.52
|
| Rate for Payer: Cash Price |
$17,515.20
|
| Rate for Payer: Devoted Health Medicare |
$9,925.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,049.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,434.40
|
| Rate for Payer: Health Management Network Commercial |
$24,813.20
|
| Rate for Payer: Humana Medicare |
$9,049.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$26,272.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14,887.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,049.52
|
| Rate for Payer: MDX Hawaii PPO |
$28,316.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,049.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,049.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,049.52
|
| Rate for Payer: University Health Alliance Commercial |
$16,347.52
|
|
|
MOMENTUM EL ICD R
|
Facility
|
IP
|
$29,192.00
|
|
|
Service Code
|
HCPCS C1721
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$16,347.52 |
| Max. Negotiated Rate |
$28,316.24 |
| Rate for Payer: Cash Price |
$17,515.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,434.40
|
| Rate for Payer: Health Management Network Commercial |
$24,813.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$26,272.80
|
| Rate for Payer: MDX Hawaii PPO |
$28,316.24
|
| Rate for Payer: University Health Alliance Commercial |
$16,347.52
|
|
|
MOMENTUM EL ICD VR
|
Facility
|
IP
|
$24,586.00
|
|
|
Service Code
|
HCPCS C1722
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$13,768.16 |
| Max. Negotiated Rate |
$23,848.42 |
| Rate for Payer: Cash Price |
$14,751.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17,210.20
|
| Rate for Payer: Health Management Network Commercial |
$20,898.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$22,127.40
|
| Rate for Payer: MDX Hawaii PPO |
$23,848.42
|
| Rate for Payer: University Health Alliance Commercial |
$13,768.16
|
|
|
MOMENTUM EL ICD VR
|
Facility
|
OP
|
$24,586.00
|
|
|
Service Code
|
HCPCS C1722
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$7,621.66 |
| Max. Negotiated Rate |
$23,848.42 |
| Rate for Payer: AlohaCare Medicaid |
$12,293.00
|
| Rate for Payer: AlohaCare Medicare |
$7,621.66
|
| Rate for Payer: Cash Price |
$14,751.60
|
| Rate for Payer: Devoted Health Medicare |
$8,359.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,621.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17,210.20
|
| Rate for Payer: Health Management Network Commercial |
$20,898.10
|
| Rate for Payer: Humana Medicare |
$7,621.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$22,127.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12,538.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,621.66
|
| Rate for Payer: MDX Hawaii PPO |
$23,848.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,621.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,621.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,621.66
|
| Rate for Payer: University Health Alliance Commercial |
$13,768.16
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904680861
|
|
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
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 68084087501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904680861
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
MONTELUKAST 10 MG TABLET [22509]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 68084087501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
MORCELLS MYRIAD PW02NA0500
|
Facility
|
OP
|
$2,013.00
|
|
|
Service Code
|
HCPCS A2033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$624.03 |
| Max. Negotiated Rate |
$1,952.61 |
| Rate for Payer: AlohaCare Medicaid |
$1,006.50
|
| Rate for Payer: AlohaCare Medicare |
$624.03
|
| Rate for Payer: Cash Price |
$1,207.80
|
| Rate for Payer: Devoted Health Medicare |
$684.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$624.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,912.35
|
| Rate for Payer: Health Management Network Commercial |
$1,711.05
|
| Rate for Payer: Humana Medicare |
$624.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,811.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,026.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$624.03
|
| Rate for Payer: MDX Hawaii PPO |
$1,952.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$624.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$624.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,207.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$624.03
|
| Rate for Payer: University Health Alliance Commercial |
$1,467.28
|
|
|
MORCELLS MYRIAD PW02NA0500
|
Facility
|
IP
|
$2,013.00
|
|
|
Service Code
|
HCPCS A2033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,711.05 |
| Max. Negotiated Rate |
$1,952.61 |
| Rate for Payer: Cash Price |
$1,207.80
|
| Rate for Payer: Health Management Network Commercial |
$1,711.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,811.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,952.61
|
|
|
MORDELLS MYRIAD PW01NA1000
|
Facility
|
OP
|
$3,675.00
|
|
|
Service Code
|
HCPCS A2033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,139.25 |
| Max. Negotiated Rate |
$3,564.75 |
| Rate for Payer: AlohaCare Medicaid |
$1,837.50
|
| Rate for Payer: AlohaCare Medicare |
$1,139.25
|
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Devoted Health Medicare |
$1,249.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,139.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,491.25
|
| Rate for Payer: Health Management Network Commercial |
$3,123.75
|
| Rate for Payer: Humana Medicare |
$1,139.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,307.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,874.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,139.25
|
| Rate for Payer: MDX Hawaii PPO |
$3,564.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,139.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,139.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,205.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,139.25
|
| Rate for Payer: University Health Alliance Commercial |
$2,678.71
|
|
|
MORDELLS MYRIAD PW01NA1000
|
Facility
|
IP
|
$3,675.00
|
|
|
Service Code
|
HCPCS A2033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,123.75 |
| Max. Negotiated Rate |
$3,564.75 |
| Rate for Payer: Cash Price |
$2,205.00
|
| Rate for Payer: Health Management Network Commercial |
$3,123.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,307.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,564.75
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68094000159
|
|
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
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68094000162
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68094000159
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00121090405
|
|
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
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68094000162
|
|
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
|
|
|
MORPHINE 10 MG/5 ML ORAL SOLUTION [5176]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00121090405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
