|
Factor V Leiden FSI
|
Facility
|
IP
|
$288.00
|
|
|
Service Code
|
HCPCS 81241
|
| Hospital Charge Code |
11373878
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$244.80 |
| Max. Negotiated Rate |
$279.36 |
| Rate for Payer: Cash Price |
$187.20
|
| Rate for Payer: Health Management Network Commercial |
$244.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.20
|
| Rate for Payer: MDX Hawaii PPO |
$279.36
|
|
|
famotidine 20 mg/2ml vial [HHSC]
|
Facility
|
OP
|
$5.48
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
2500318
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: AlohaCare Medicaid |
$2.74
|
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$2.74
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cash Price |
$3.90
|
| Rate for Payer: Cash Price |
$3.90
|
| Rate for Payer: Devoted Health Medicare |
$3.01
|
| Rate for Payer: Devoted Health Medicare |
$3.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$4.66
|
| Rate for Payer: Humana Medicare |
$3.00
|
| Rate for Payer: Humana Medicare |
$2.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.00
|
| Rate for Payer: MDX Hawaii PPO |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.00
|
| Rate for Payer: University Health Alliance Commercial |
$3.99
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
famotidine 20 mg/2ml vial [HHSC]
|
Facility
|
IP
|
$5.48
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
2500318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cash Price |
$3.90
|
| Rate for Payer: Health Management Network Commercial |
$4.66
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$5.32
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$8.44
|
|
|
Service Code
|
NDC 50268030315
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$8.19 |
| Rate for Payer: AlohaCare Medicaid |
$4.22
|
| Rate for Payer: AlohaCare Medicare |
$4.22
|
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Devoted Health Medicare |
$4.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.02
|
| Rate for Payer: Health Management Network Commercial |
$7.17
|
| Rate for Payer: Humana Medicare |
$4.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.22
|
| Rate for Payer: MDX Hawaii PPO |
$8.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.06
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.22
|
| Rate for Payer: University Health Alliance Commercial |
$6.15
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$13.47
|
|
|
Service Code
|
NDC 65862085901
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.45 |
| Max. Negotiated Rate |
$13.07 |
| Rate for Payer: Cash Price |
$8.76
|
| Rate for Payer: Health Management Network Commercial |
$11.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.12
|
| Rate for Payer: MDX Hawaii PPO |
$13.07
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$13.47
|
|
|
Service Code
|
NDC 68001039700
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.45 |
| Max. Negotiated Rate |
$13.07 |
| Rate for Payer: Cash Price |
$8.76
|
| Rate for Payer: Health Management Network Commercial |
$11.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.12
|
| Rate for Payer: MDX Hawaii PPO |
$13.07
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687059501
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268029915
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$13.47
|
|
|
Service Code
|
NDC 68001039700
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$13.07 |
| Rate for Payer: AlohaCare Medicaid |
$6.74
|
| Rate for Payer: AlohaCare Medicare |
$6.74
|
| Rate for Payer: Cash Price |
$8.76
|
| Rate for Payer: Devoted Health Medicare |
$7.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.80
|
| Rate for Payer: Health Management Network Commercial |
$11.45
|
| Rate for Payer: Humana Medicare |
$6.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.74
|
| Rate for Payer: MDX Hawaii PPO |
$13.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.74
|
| Rate for Payer: University Health Alliance Commercial |
$9.82
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687059501
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$13.47
|
|
|
Service Code
|
NDC 65862085901
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.74 |
| Max. Negotiated Rate |
$13.07 |
| Rate for Payer: AlohaCare Medicaid |
$6.74
|
| Rate for Payer: AlohaCare Medicare |
$6.74
|
| Rate for Payer: Cash Price |
$8.76
|
| Rate for Payer: Devoted Health Medicare |
$7.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.80
|
| Rate for Payer: Health Management Network Commercial |
$11.45
|
| Rate for Payer: Humana Medicare |
$6.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.74
|
| Rate for Payer: MDX Hawaii PPO |
$13.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.74
|
| Rate for Payer: University Health Alliance Commercial |
$9.82
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 63739064510
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$8.44
|
|
|
Service Code
|
NDC 50268030315
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.17 |
| Max. Negotiated Rate |
$8.19 |
| Rate for Payer: Cash Price |
$5.49
|
| Rate for Payer: Health Management Network Commercial |
$7.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.60
|
| Rate for Payer: MDX Hawaii PPO |
$8.19
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 63739064510
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
famotidine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268029915
|
| Hospital Charge Code |
2500999
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
fat emulsion, 20% IV 250 mL [HHSC]
|
Facility
|
IP
|
$135.06
|
|
|
Service Code
|
NDC 00264446030
|
| Hospital Charge Code |
2500319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$114.80 |
| Max. Negotiated Rate |
$131.01 |
| Rate for Payer: Cash Price |
$87.79
|
| Rate for Payer: Health Management Network Commercial |
$114.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.55
|
| Rate for Payer: MDX Hawaii PPO |
$131.01
|
|
|
fat emulsion, 20% IV 250 mL [HHSC]
|
Facility
|
OP
|
$135.06
|
|
|
Service Code
|
NDC 00264446030
|
| Hospital Charge Code |
2500319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.53 |
| Max. Negotiated Rate |
$131.01 |
| Rate for Payer: AlohaCare Medicaid |
$67.53
|
| Rate for Payer: AlohaCare Medicare |
$67.53
|
| Rate for Payer: Cash Price |
$87.79
|
| Rate for Payer: Devoted Health Medicare |
$74.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$67.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$128.31
|
| Rate for Payer: Health Management Network Commercial |
$114.80
|
| Rate for Payer: Humana Medicare |
$67.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$121.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$67.53
|
| Rate for Payer: MDX Hawaii PPO |
$131.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$67.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$67.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$67.53
|
| Rate for Payer: University Health Alliance Commercial |
$98.45
|
|
|
Fecal Management System
|
Facility
|
IP
|
$1,005.00
|
|
|
Service Code
|
HCPCS 45999
|
| Hospital Charge Code |
1363012
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$854.25 |
| Max. Negotiated Rate |
$974.85 |
| Rate for Payer: Cash Price |
$653.25
|
| Rate for Payer: Health Management Network Commercial |
$854.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$904.50
|
| Rate for Payer: MDX Hawaii PPO |
$974.85
|
|
|
Fecal Management System
|
Facility
|
OP
|
$1,005.00
|
|
|
Service Code
|
HCPCS 45999
|
| Hospital Charge Code |
1363012
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$502.50
|
| Rate for Payer: AlohaCare Medicare |
$502.50
|
| Rate for Payer: Cash Price |
$653.25
|
| Rate for Payer: Cash Price |
$653.25
|
| Rate for Payer: Cash Price |
$653.25
|
| Rate for Payer: Devoted Health Medicare |
$552.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,187.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$502.50
|
| Rate for Payer: Health Management Network Commercial |
$854.25
|
| Rate for Payer: Humana Medicare |
$502.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$904.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$502.50
|
| Rate for Payer: MDX Hawaii PPO |
$974.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$502.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$502.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$502.50
|
| Rate for Payer: University Health Alliance Commercial |
$732.54
|
|
|
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
|
Facility
|
IP
|
$19,580.93
|
|
|
Service Code
|
MSDRG 748
|
| Min. Negotiated Rate |
$19,580.93 |
| Max. Negotiated Rate |
$19,580.93 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19,580.93
|
|
|
fentaNYL 1000 mcg/20 mL (PF) vial [HHSC]
|
Facility
|
OP
|
$59.35
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2501137
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$57.57 |
| Rate for Payer: AlohaCare Medicaid |
$29.68
|
| Rate for Payer: AlohaCare Medicaid |
$27.52
|
| Rate for Payer: AlohaCare Medicare |
$27.52
|
| Rate for Payer: AlohaCare Medicare |
$29.68
|
| Rate for Payer: Cash Price |
$35.77
|
| Rate for Payer: Cash Price |
$35.77
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Devoted Health Medicare |
$30.27
|
| Rate for Payer: Devoted Health Medicare |
$32.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.38
|
| Rate for Payer: Health Management Network Commercial |
$46.78
|
| Rate for Payer: Health Management Network Commercial |
$50.45
|
| Rate for Payer: Humana Medicare |
$27.52
|
| Rate for Payer: Humana Medicare |
$29.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.68
|
| Rate for Payer: MDX Hawaii PPO |
$53.38
|
| Rate for Payer: MDX Hawaii PPO |
$57.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.52
|
| Rate for Payer: University Health Alliance Commercial |
$40.11
|
| Rate for Payer: University Health Alliance Commercial |
$43.26
|
|
|
fentaNYL 1000 mcg/20 mL (PF) vial [HHSC]
|
Facility
|
IP
|
$55.03
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2501137
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.78 |
| Max. Negotiated Rate |
$53.38 |
| Rate for Payer: Cash Price |
$35.77
|
| Rate for Payer: Cash Price |
$38.58
|
| Rate for Payer: Health Management Network Commercial |
$50.45
|
| Rate for Payer: Health Management Network Commercial |
$46.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.41
|
| Rate for Payer: MDX Hawaii PPO |
$53.38
|
| Rate for Payer: MDX Hawaii PPO |
$57.57
|
|
|
fentaNYL 100mcg/2mL (PF) injection [HHSC]
|
Facility
|
IP
|
$5.34
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2500880
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.54 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Health Management Network Commercial |
$10.24
|
| Rate for Payer: Health Management Network Commercial |
$4.54
|
| Rate for Payer: Health Management Network Commercial |
$6.31
|
| Rate for Payer: Health Management Network Commercial |
$8.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.81
|
| Rate for Payer: MDX Hawaii PPO |
$11.69
|
| Rate for Payer: MDX Hawaii PPO |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$9.45
|
| Rate for Payer: MDX Hawaii PPO |
$5.18
|
|
|
fentaNYL 100mcg/2mL (PF) injection [HHSC]
|
Facility
|
OP
|
$7.42
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
2500880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: AlohaCare Medicaid |
$3.71
|
| Rate for Payer: AlohaCare Medicaid |
$4.87
|
| Rate for Payer: AlohaCare Medicaid |
$2.67
|
| Rate for Payer: AlohaCare Medicaid |
$6.03
|
| Rate for Payer: AlohaCare Medicare |
$6.03
|
| Rate for Payer: AlohaCare Medicare |
$2.67
|
| Rate for Payer: AlohaCare Medicare |
$3.71
|
| Rate for Payer: AlohaCare Medicare |
$4.87
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Cash Price |
$4.82
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cash Price |
$6.33
|
| Rate for Payer: Devoted Health Medicare |
$2.94
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Devoted Health Medicare |
$6.63
|
| Rate for Payer: Devoted Health Medicare |
$5.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.71
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.25
|
| Rate for Payer: Health Management Network Commercial |
$8.28
|
| Rate for Payer: Health Management Network Commercial |
$4.54
|
| Rate for Payer: Health Management Network Commercial |
$10.24
|
| Rate for Payer: Health Management Network Commercial |
$6.31
|
| Rate for Payer: Humana Medicare |
$2.67
|
| Rate for Payer: Humana Medicare |
$6.03
|
| Rate for Payer: Humana Medicare |
$3.71
|
| Rate for Payer: Humana Medicare |
$4.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.03
|
| Rate for Payer: MDX Hawaii PPO |
$9.45
|
| Rate for Payer: MDX Hawaii PPO |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$5.18
|
| Rate for Payer: MDX Hawaii PPO |
$11.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.03
|
| Rate for Payer: University Health Alliance Commercial |
$7.10
|
| Rate for Payer: University Health Alliance Commercial |
$5.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.78
|
| Rate for Payer: University Health Alliance Commercial |
$3.89
|
|
|
fentaNYL 100 mcg/hr patch [HHSC]
|
Facility
|
OP
|
$374.35
|
|
|
Service Code
|
NDC 60505700902
|
| Hospital Charge Code |
2500320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$187.18 |
| Max. Negotiated Rate |
$363.12 |
| Rate for Payer: AlohaCare Medicaid |
$187.18
|
| Rate for Payer: AlohaCare Medicare |
$187.18
|
| Rate for Payer: Cash Price |
$243.33
|
| Rate for Payer: Devoted Health Medicare |
$205.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$187.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$355.63
|
| Rate for Payer: Health Management Network Commercial |
$318.20
|
| Rate for Payer: Humana Medicare |
$187.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$336.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$190.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$187.18
|
| Rate for Payer: MDX Hawaii PPO |
$363.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$187.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$187.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$224.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$187.18
|
| Rate for Payer: University Health Alliance Commercial |
$272.86
|
|
