Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$286.12

Service Code	NDC 00406900076
Hospital Charge Code	2500320
Hospital Revenue Code	250
Min. Negotiated Rate	$143.06
Max. Negotiated Rate	$277.54
Rate for Payer: AlohaCare Medicaid	$143.06
Rate for Payer: AlohaCare Medicare	$143.06
Rate for Payer: Cash Price	$185.98
Rate for Payer: Devoted Health Medicare	$157.37
Rate for Payer: Hawaii Medical Service Association Medicare	$143.06
Rate for Payer: Hawaii Western Management Group Commercial	$271.81
Rate for Payer: Health Management Network Commercial	$243.20
Rate for Payer: Humana Medicare	$143.06
Rate for Payer: Kaiser Permanente Commercial	$257.51
Rate for Payer: Kaiser Permanente Medicaid	$145.92
Rate for Payer: Kaiser Permanente Medicare	$143.06
Rate for Payer: MDX Hawaii PPO	$277.54
Rate for Payer: Ohana Health Plan Medicaid	$143.06
Rate for Payer: Ohana Health Plan Medicare	$143.06
Rate for Payer: UnitedHealthcare Medicaid	$171.67
Rate for Payer: UnitedHealthcare Medicare	$143.06
Rate for Payer: University Health Alliance Commercial	$208.55

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$286.12

Service Code	NDC 00378912498
Hospital Charge Code	2500320
Hospital Revenue Code	250
Min. Negotiated Rate	$243.20
Max. Negotiated Rate	$277.54
Rate for Payer: Cash Price	$185.98
Rate for Payer: Health Management Network Commercial	$243.20
Rate for Payer: Kaiser Permanente Commercial	$257.51
Rate for Payer: MDX Hawaii PPO	$277.54

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$374.35

Service Code	NDC 60505700902
Hospital Charge Code	2500320
Hospital Revenue Code	250
Min. Negotiated Rate	$318.20
Max. Negotiated Rate	$363.12
Rate for Payer: Cash Price	$243.33
Rate for Payer: Health Management Network Commercial	$318.20
Rate for Payer: Kaiser Permanente Commercial	$336.92
Rate for Payer: MDX Hawaii PPO	$363.12

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$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

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$286.12

Service Code	NDC 00378912498
Hospital Charge Code	2500320
Hospital Revenue Code	250
Min. Negotiated Rate	$143.06
Max. Negotiated Rate	$277.54
Rate for Payer: AlohaCare Medicaid	$143.06
Rate for Payer: AlohaCare Medicare	$143.06
Rate for Payer: Cash Price	$185.98
Rate for Payer: Devoted Health Medicare	$157.37
Rate for Payer: Hawaii Medical Service Association Medicare	$143.06
Rate for Payer: Hawaii Western Management Group Commercial	$271.81
Rate for Payer: Health Management Network Commercial	$243.20
Rate for Payer: Humana Medicare	$143.06
Rate for Payer: Kaiser Permanente Commercial	$257.51
Rate for Payer: Kaiser Permanente Medicaid	$145.92
Rate for Payer: Kaiser Permanente Medicare	$143.06
Rate for Payer: MDX Hawaii PPO	$277.54
Rate for Payer: Ohana Health Plan Medicaid	$143.06
Rate for Payer: Ohana Health Plan Medicare	$143.06
Rate for Payer: UnitedHealthcare Medicaid	$171.67
Rate for Payer: UnitedHealthcare Medicare	$143.06
Rate for Payer: University Health Alliance Commercial	$208.55

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$286.12

Service Code	NDC 00406910076
Hospital Charge Code	2500320
Hospital Revenue Code	250
Min. Negotiated Rate	$143.06
Max. Negotiated Rate	$277.54
Rate for Payer: AlohaCare Medicaid	$143.06
Rate for Payer: AlohaCare Medicare	$143.06
Rate for Payer: Cash Price	$185.98
Rate for Payer: Devoted Health Medicare	$157.37
Rate for Payer: Hawaii Medical Service Association Medicare	$143.06
Rate for Payer: Hawaii Western Management Group Commercial	$271.81
Rate for Payer: Health Management Network Commercial	$243.20
Rate for Payer: Humana Medicare	$143.06
Rate for Payer: Kaiser Permanente Commercial	$257.51
Rate for Payer: Kaiser Permanente Medicaid	$145.92
Rate for Payer: Kaiser Permanente Medicare	$143.06
Rate for Payer: MDX Hawaii PPO	$277.54
Rate for Payer: Ohana Health Plan Medicaid	$143.06
Rate for Payer: Ohana Health Plan Medicare	$143.06
Rate for Payer: UnitedHealthcare Medicaid	$171.67
Rate for Payer: UnitedHealthcare Medicare	$143.06
Rate for Payer: University Health Alliance Commercial	$208.55

fentaNYL 100 mcg/hr patch [HHSC]

Facility

$286.12

Service Code	NDC 00406900076
Hospital Charge Code	2500320
Hospital Revenue Code	250
Min. Negotiated Rate	$243.20
Max. Negotiated Rate	$277.54
Rate for Payer: Cash Price	$185.98
Rate for Payer: Health Management Network Commercial	$243.20
Rate for Payer: Kaiser Permanente Commercial	$257.51
Rate for Payer: MDX Hawaii PPO	$277.54

fentaNYL 12 mcg/hr patch [HHSC]

Facility

$104.22

Service Code	NDC 00406901276
Hospital Charge Code	2500321
Hospital Revenue Code	250
Min. Negotiated Rate	$52.11
Max. Negotiated Rate	$101.09
Rate for Payer: AlohaCare Medicaid	$52.11
Rate for Payer: AlohaCare Medicare	$52.11
Rate for Payer: Cash Price	$67.74
Rate for Payer: Devoted Health Medicare	$57.32
Rate for Payer: Hawaii Medical Service Association Medicare	$52.11
Rate for Payer: Hawaii Western Management Group Commercial	$99.01
Rate for Payer: Health Management Network Commercial	$88.59
Rate for Payer: Humana Medicare	$52.11
Rate for Payer: Kaiser Permanente Commercial	$93.80
Rate for Payer: Kaiser Permanente Medicaid	$53.15
Rate for Payer: Kaiser Permanente Medicare	$52.11
Rate for Payer: MDX Hawaii PPO	$101.09
Rate for Payer: Ohana Health Plan Medicaid	$52.11
Rate for Payer: Ohana Health Plan Medicare	$52.11
Rate for Payer: UnitedHealthcare Medicaid	$62.53
Rate for Payer: UnitedHealthcare Medicare	$52.11
Rate for Payer: University Health Alliance Commercial	$75.97

fentaNYL 12 mcg/hr patch [HHSC]

Facility

$104.22

Service Code	NDC 00406901276
Hospital Charge Code	2500321
Hospital Revenue Code	250
Min. Negotiated Rate	$88.59
Max. Negotiated Rate	$101.09
Rate for Payer: Cash Price	$67.74
Rate for Payer: Health Management Network Commercial	$88.59
Rate for Payer: Kaiser Permanente Commercial	$93.80
Rate for Payer: MDX Hawaii PPO	$101.09

fentaNYL 12 mcg/hr patch [HHSC]

Facility

$103.01

Service Code	NDC 00378911998
Hospital Charge Code	2500321
Hospital Revenue Code	250
Min. Negotiated Rate	$51.51
Max. Negotiated Rate	$99.92
Rate for Payer: AlohaCare Medicaid	$51.51
Rate for Payer: AlohaCare Medicare	$51.51
Rate for Payer: Cash Price	$66.96
Rate for Payer: Devoted Health Medicare	$56.66
Rate for Payer: Hawaii Medical Service Association Medicare	$51.51
Rate for Payer: Hawaii Western Management Group Commercial	$97.86
Rate for Payer: Health Management Network Commercial	$87.56
Rate for Payer: Humana Medicare	$51.51
Rate for Payer: Kaiser Permanente Commercial	$92.71
Rate for Payer: Kaiser Permanente Medicaid	$52.54
Rate for Payer: Kaiser Permanente Medicare	$51.51
Rate for Payer: MDX Hawaii PPO	$99.92
Rate for Payer: Ohana Health Plan Medicaid	$51.51
Rate for Payer: Ohana Health Plan Medicare	$51.51
Rate for Payer: UnitedHealthcare Medicaid	$61.81
Rate for Payer: UnitedHealthcare Medicare	$51.51
Rate for Payer: University Health Alliance Commercial	$75.08

fentaNYL 12 mcg/hr patch [HHSC]

Facility

$103.01

Service Code	NDC 00406911276
Hospital Charge Code	2500321
Hospital Revenue Code	250
Min. Negotiated Rate	$87.56
Max. Negotiated Rate	$99.92
Rate for Payer: Cash Price	$66.96
Rate for Payer: Health Management Network Commercial	$87.56
Rate for Payer: Kaiser Permanente Commercial	$92.71
Rate for Payer: MDX Hawaii PPO	$99.92

fentaNYL 12 mcg/hr patch [HHSC]

Facility

$103.01

Service Code	NDC 00378911998
Hospital Charge Code	2500321
Hospital Revenue Code	250
Min. Negotiated Rate	$87.56
Max. Negotiated Rate	$99.92
Rate for Payer: Cash Price	$66.96
Rate for Payer: Health Management Network Commercial	$87.56
Rate for Payer: Kaiser Permanente Commercial	$92.71
Rate for Payer: MDX Hawaii PPO	$99.92

fentaNYL 12 mcg/hr patch [HHSC]

Facility

$103.01

Service Code	NDC 00406911276
Hospital Charge Code	2500321
Hospital Revenue Code	250
Min. Negotiated Rate	$51.51
Max. Negotiated Rate	$99.92
Rate for Payer: AlohaCare Medicaid	$51.51
Rate for Payer: AlohaCare Medicare	$51.51
Rate for Payer: Cash Price	$66.96
Rate for Payer: Devoted Health Medicare	$56.66
Rate for Payer: Hawaii Medical Service Association Medicare	$51.51
Rate for Payer: Hawaii Western Management Group Commercial	$97.86
Rate for Payer: Health Management Network Commercial	$87.56
Rate for Payer: Humana Medicare	$51.51
Rate for Payer: Kaiser Permanente Commercial	$92.71
Rate for Payer: Kaiser Permanente Medicaid	$52.54
Rate for Payer: Kaiser Permanente Medicare	$51.51
Rate for Payer: MDX Hawaii PPO	$99.92
Rate for Payer: Ohana Health Plan Medicaid	$51.51
Rate for Payer: Ohana Health Plan Medicare	$51.51
Rate for Payer: UnitedHealthcare Medicaid	$61.81
Rate for Payer: UnitedHealthcare Medicare	$51.51
Rate for Payer: University Health Alliance Commercial	$75.08

fentaNYL 250mcg/5mL (PF) injection [HHSC]

Facility

$12.47

Service Code	HCPCS J3010
Hospital Charge Code	2500881
Hospital Revenue Code	250
Min. Negotiated Rate	$10.60
Max. Negotiated Rate	$12.10
Rate for Payer: Cash Price	$8.11
Rate for Payer: Cash Price	$7.01
Rate for Payer: Cash Price	$13.01
Rate for Payer: Cash Price	$11.00
Rate for Payer: Health Management Network Commercial	$9.16
Rate for Payer: Health Management Network Commercial	$10.60
Rate for Payer: Health Management Network Commercial	$14.38
Rate for Payer: Health Management Network Commercial	$17.02
Rate for Payer: Kaiser Permanente Commercial	$9.70
Rate for Payer: Kaiser Permanente Commercial	$18.02
Rate for Payer: Kaiser Permanente Commercial	$15.23
Rate for Payer: Kaiser Permanente Commercial	$11.22
Rate for Payer: MDX Hawaii PPO	$10.46
Rate for Payer: MDX Hawaii PPO	$16.41
Rate for Payer: MDX Hawaii PPO	$19.42
Rate for Payer: MDX Hawaii PPO	$12.10

fentaNYL 250mcg/5mL (PF) injection [HHSC]

Facility

$16.92

Service Code	HCPCS J3010
Hospital Charge Code	2500881
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$16.41
Rate for Payer: AlohaCare Medicaid	$8.46
Rate for Payer: AlohaCare Medicaid	$10.01
Rate for Payer: AlohaCare Medicaid	$6.24
Rate for Payer: AlohaCare Medicaid	$5.39
Rate for Payer: AlohaCare Medicare	$5.39
Rate for Payer: AlohaCare Medicare	$6.24
Rate for Payer: AlohaCare Medicare	$8.46
Rate for Payer: AlohaCare Medicare	$10.01
Rate for Payer: Cash Price	$7.01
Rate for Payer: Cash Price	$11.00
Rate for Payer: Cash Price	$8.11
Rate for Payer: Cash Price	$8.11
Rate for Payer: Cash Price	$11.00
Rate for Payer: Cash Price	$13.01
Rate for Payer: Cash Price	$7.01
Rate for Payer: Cash Price	$13.01
Rate for Payer: Devoted Health Medicare	$6.86
Rate for Payer: Devoted Health Medicare	$9.31
Rate for Payer: Devoted Health Medicare	$5.93
Rate for Payer: Devoted Health Medicare	$11.01
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	$6.24
Rate for Payer: Hawaii Medical Service Association Medicare	$10.01
Rate for Payer: Hawaii Medical Service Association Medicare	$5.39
Rate for Payer: Hawaii Medical Service Association Medicare	$8.46
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	$16.07
Rate for Payer: Hawaii Western Management Group Commercial	$10.24
Rate for Payer: Hawaii Western Management Group Commercial	$11.85
Rate for Payer: Hawaii Western Management Group Commercial	$19.02
Rate for Payer: Health Management Network Commercial	$17.02
Rate for Payer: Health Management Network Commercial	$10.60
Rate for Payer: Health Management Network Commercial	$9.16
Rate for Payer: Health Management Network Commercial	$14.38
Rate for Payer: Humana Medicare	$6.24
Rate for Payer: Humana Medicare	$5.39
Rate for Payer: Humana Medicare	$8.46
Rate for Payer: Humana Medicare	$10.01
Rate for Payer: Kaiser Permanente Commercial	$15.23
Rate for Payer: Kaiser Permanente Commercial	$11.22
Rate for Payer: Kaiser Permanente Commercial	$9.70
Rate for Payer: Kaiser Permanente Commercial	$18.02
Rate for Payer: Kaiser Permanente Medicaid	$5.50
Rate for Payer: Kaiser Permanente Medicaid	$8.63
Rate for Payer: Kaiser Permanente Medicaid	$10.21
Rate for Payer: Kaiser Permanente Medicaid	$6.36
Rate for Payer: Kaiser Permanente Medicare	$10.01
Rate for Payer: Kaiser Permanente Medicare	$6.24
Rate for Payer: Kaiser Permanente Medicare	$8.46
Rate for Payer: Kaiser Permanente Medicare	$5.39
Rate for Payer: MDX Hawaii PPO	$19.42
Rate for Payer: MDX Hawaii PPO	$16.41
Rate for Payer: MDX Hawaii PPO	$12.10
Rate for Payer: MDX Hawaii PPO	$10.46
Rate for Payer: Ohana Health Plan Medicaid	$6.24
Rate for Payer: Ohana Health Plan Medicaid	$5.39
Rate for Payer: Ohana Health Plan Medicaid	$8.46
Rate for Payer: Ohana Health Plan Medicaid	$10.01
Rate for Payer: Ohana Health Plan Medicare	$6.24
Rate for Payer: Ohana Health Plan Medicare	$5.39
Rate for Payer: Ohana Health Plan Medicare	$8.46
Rate for Payer: Ohana Health Plan Medicare	$10.01
Rate for Payer: UnitedHealthcare Medicaid	$7.48
Rate for Payer: UnitedHealthcare Medicaid	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$12.01
Rate for Payer: UnitedHealthcare Medicaid	$6.47
Rate for Payer: UnitedHealthcare Medicare	$8.46
Rate for Payer: UnitedHealthcare Medicare	$10.01
Rate for Payer: UnitedHealthcare Medicare	$6.24
Rate for Payer: UnitedHealthcare Medicare	$5.39
Rate for Payer: University Health Alliance Commercial	$14.59
Rate for Payer: University Health Alliance Commercial	$12.33
Rate for Payer: University Health Alliance Commercial	$7.86
Rate for Payer: University Health Alliance Commercial	$9.09

fentaNYL 25 mcg/hr patch [HHSC]

Facility

$78.43

Service Code	NDC 00406912576
Hospital Charge Code	2500322
Hospital Revenue Code	250
Min. Negotiated Rate	$39.22
Max. Negotiated Rate	$76.08
Rate for Payer: AlohaCare Medicaid	$39.22
Rate for Payer: AlohaCare Medicare	$39.22
Rate for Payer: Cash Price	$50.98
Rate for Payer: Devoted Health Medicare	$43.14
Rate for Payer: Hawaii Medical Service Association Medicare	$39.22
Rate for Payer: Hawaii Western Management Group Commercial	$74.51
Rate for Payer: Health Management Network Commercial	$66.67
Rate for Payer: Humana Medicare	$39.22
Rate for Payer: Kaiser Permanente Commercial	$70.59
Rate for Payer: Kaiser Permanente Medicaid	$40.00
Rate for Payer: Kaiser Permanente Medicare	$39.22
Rate for Payer: MDX Hawaii PPO	$76.08
Rate for Payer: Ohana Health Plan Medicaid	$39.22
Rate for Payer: Ohana Health Plan Medicare	$39.22
Rate for Payer: UnitedHealthcare Medicaid	$47.06
Rate for Payer: UnitedHealthcare Medicare	$39.22
Rate for Payer: University Health Alliance Commercial	$57.17

fentaNYL 25 mcg/hr patch [HHSC]

Facility

$78.43

Service Code	NDC 00406912576
Hospital Charge Code	2500322
Hospital Revenue Code	250
Min. Negotiated Rate	$66.67
Max. Negotiated Rate	$76.08
Rate for Payer: Cash Price	$50.98
Rate for Payer: Health Management Network Commercial	$66.67
Rate for Payer: Kaiser Permanente Commercial	$70.59
Rate for Payer: MDX Hawaii PPO	$76.08

fentaNYL 25 mcg/hr patch [HHSC]

Facility

$78.43

Service Code	NDC 00406902576
Hospital Charge Code	2500322
Hospital Revenue Code	250
Min. Negotiated Rate	$39.22
Max. Negotiated Rate	$76.08
Rate for Payer: AlohaCare Medicaid	$39.22
Rate for Payer: AlohaCare Medicare	$39.22
Rate for Payer: Cash Price	$50.98
Rate for Payer: Devoted Health Medicare	$43.14
Rate for Payer: Hawaii Medical Service Association Medicare	$39.22
Rate for Payer: Hawaii Western Management Group Commercial	$74.51
Rate for Payer: Health Management Network Commercial	$66.67
Rate for Payer: Humana Medicare	$39.22
Rate for Payer: Kaiser Permanente Commercial	$70.59
Rate for Payer: Kaiser Permanente Medicaid	$40.00
Rate for Payer: Kaiser Permanente Medicare	$39.22
Rate for Payer: MDX Hawaii PPO	$76.08
Rate for Payer: Ohana Health Plan Medicaid	$39.22
Rate for Payer: Ohana Health Plan Medicare	$39.22
Rate for Payer: UnitedHealthcare Medicaid	$47.06
Rate for Payer: UnitedHealthcare Medicare	$39.22
Rate for Payer: University Health Alliance Commercial	$57.17

fentaNYL 25 mcg/hr patch [HHSC]

Facility

$78.43

Service Code	NDC 00378912198
Hospital Charge Code	2500322
Hospital Revenue Code	250
Min. Negotiated Rate	$66.67
Max. Negotiated Rate	$76.08
Rate for Payer: Cash Price	$50.98
Rate for Payer: Health Management Network Commercial	$66.67
Rate for Payer: Kaiser Permanente Commercial	$70.59
Rate for Payer: MDX Hawaii PPO	$76.08

fentaNYL 25 mcg/hr patch [HHSC]

Facility

$78.43

Service Code	NDC 00378912198
Hospital Charge Code	2500322
Hospital Revenue Code	250
Min. Negotiated Rate	$39.22
Max. Negotiated Rate	$76.08
Rate for Payer: AlohaCare Medicaid	$39.22
Rate for Payer: AlohaCare Medicare	$39.22
Rate for Payer: Cash Price	$50.98
Rate for Payer: Devoted Health Medicare	$43.14
Rate for Payer: Hawaii Medical Service Association Medicare	$39.22
Rate for Payer: Hawaii Western Management Group Commercial	$74.51
Rate for Payer: Health Management Network Commercial	$66.67
Rate for Payer: Humana Medicare	$39.22
Rate for Payer: Kaiser Permanente Commercial	$70.59
Rate for Payer: Kaiser Permanente Medicaid	$40.00
Rate for Payer: Kaiser Permanente Medicare	$39.22
Rate for Payer: MDX Hawaii PPO	$76.08
Rate for Payer: Ohana Health Plan Medicaid	$39.22
Rate for Payer: Ohana Health Plan Medicare	$39.22
Rate for Payer: UnitedHealthcare Medicaid	$47.06
Rate for Payer: UnitedHealthcare Medicare	$39.22
Rate for Payer: University Health Alliance Commercial	$57.17

fentaNYL 25 mcg/hr patch [HHSC]

Facility

$78.43

Service Code	NDC 00406902576
Hospital Charge Code	2500322
Hospital Revenue Code	250
Min. Negotiated Rate	$66.67
Max. Negotiated Rate	$76.08
Rate for Payer: Cash Price	$50.98
Rate for Payer: Health Management Network Commercial	$66.67
Rate for Payer: Kaiser Permanente Commercial	$70.59
Rate for Payer: MDX Hawaii PPO	$76.08

fentanyl 2 mcg/mL-bupiv 0.0625% 250 mL premix [HHSC]

Facility

$115.96

Service Code	NDC 70004024440
Hospital Charge Code	2501104
Hospital Revenue Code	250
Min. Negotiated Rate	$98.57
Max. Negotiated Rate	$112.48
Rate for Payer: Cash Price	$75.37
Rate for Payer: Health Management Network Commercial	$98.57
Rate for Payer: Kaiser Permanente Commercial	$104.36
Rate for Payer: MDX Hawaii PPO	$112.48

fentanyl 2 mcg/mL-bupiv 0.0625% 250 mL premix [HHSC]

Facility

$115.96

Service Code	NDC 70004024440
Hospital Charge Code	2501104
Hospital Revenue Code	250
Min. Negotiated Rate	$57.98
Max. Negotiated Rate	$112.48
Rate for Payer: AlohaCare Medicaid	$57.98
Rate for Payer: AlohaCare Medicare	$57.98
Rate for Payer: Cash Price	$75.37
Rate for Payer: Devoted Health Medicare	$63.78
Rate for Payer: Hawaii Medical Service Association Medicare	$57.98
Rate for Payer: Hawaii Western Management Group Commercial	$110.16
Rate for Payer: Health Management Network Commercial	$98.57
Rate for Payer: Humana Medicare	$57.98
Rate for Payer: Kaiser Permanente Commercial	$104.36
Rate for Payer: Kaiser Permanente Medicaid	$59.14
Rate for Payer: Kaiser Permanente Medicare	$57.98
Rate for Payer: MDX Hawaii PPO	$112.48
Rate for Payer: Ohana Health Plan Medicaid	$57.98
Rate for Payer: Ohana Health Plan Medicare	$57.98
Rate for Payer: UnitedHealthcare Medicaid	$69.58
Rate for Payer: UnitedHealthcare Medicare	$57.98
Rate for Payer: University Health Alliance Commercial	$84.52

fentanyl 2 mcg/mL-bupiv 0.0625% 250 mL premix [HHSC]

Facility

$140.46

Service Code	NDC 70092126937
Hospital Charge Code	2501104
Hospital Revenue Code	250
Min. Negotiated Rate	$119.39
Max. Negotiated Rate	$136.25
Rate for Payer: Cash Price	$91.30
Rate for Payer: Health Management Network Commercial	$119.39
Rate for Payer: Kaiser Permanente Commercial	$126.41
Rate for Payer: MDX Hawaii PPO	$136.25

fentanyl 2 mcg/mL-bupiv 0.0625% 250 mL premix [HHSC]

Facility

$140.46

Service Code	NDC 70092126937
Hospital Charge Code	2501104
Hospital Revenue Code	250
Min. Negotiated Rate	$70.23
Max. Negotiated Rate	$136.25
Rate for Payer: AlohaCare Medicaid	$70.23
Rate for Payer: AlohaCare Medicare	$70.23
Rate for Payer: Cash Price	$91.30
Rate for Payer: Devoted Health Medicare	$77.25
Rate for Payer: Hawaii Medical Service Association Medicare	$70.23
Rate for Payer: Hawaii Western Management Group Commercial	$133.44
Rate for Payer: Health Management Network Commercial	$119.39
Rate for Payer: Humana Medicare	$70.23
Rate for Payer: Kaiser Permanente Commercial	$126.41
Rate for Payer: Kaiser Permanente Medicaid	$71.63
Rate for Payer: Kaiser Permanente Medicare	$70.23
Rate for Payer: MDX Hawaii PPO	$136.25
Rate for Payer: Ohana Health Plan Medicaid	$70.23
Rate for Payer: Ohana Health Plan Medicare	$70.23
Rate for Payer: UnitedHealthcare Medicaid	$84.28
Rate for Payer: UnitedHealthcare Medicare	$70.23
Rate for Payer: University Health Alliance Commercial	$102.38

Know your out-of-pocket cost for care.

All Charges