|
FIXATN SCREW WASHER,RETROGRADE FEM NAIL
|
Facility
|
OP
|
$519.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12984240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$259.50 |
| Max. Negotiated Rate |
$503.43 |
| Rate for Payer: AlohaCare Medicaid |
$259.50
|
| Rate for Payer: AlohaCare Medicare |
$259.50
|
| Rate for Payer: Cash Price |
$337.35
|
| Rate for Payer: Devoted Health Medicare |
$285.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$259.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$363.30
|
| Rate for Payer: Health Management Network Commercial |
$441.15
|
| Rate for Payer: Humana Medicare |
$259.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$467.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$264.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$259.50
|
| Rate for Payer: MDX Hawaii PPO |
$503.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$259.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$259.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$259.50
|
| Rate for Payer: University Health Alliance Commercial |
$290.64
|
|
|
FIXATN SCREW WASHER,RETROGRADE FEM NAIL
|
Facility
|
IP
|
$519.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
12984240
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$290.64 |
| Max. Negotiated Rate |
$503.43 |
| Rate for Payer: Cash Price |
$337.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$363.30
|
| Rate for Payer: Health Management Network Commercial |
$441.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$467.10
|
| Rate for Payer: MDX Hawaii PPO |
$503.43
|
| Rate for Payer: University Health Alliance Commercial |
$290.64
|
|
|
FK506 (Prograf) FSI
|
Facility
|
OP
|
$157.00
|
|
|
Service Code
|
HCPCS 80197
|
| Hospital Charge Code |
8228868
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: AlohaCare Medicaid |
$78.50
|
| Rate for Payer: AlohaCare Medicare |
$78.50
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Devoted Health Medicare |
$86.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.97
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.73
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Humana Medicare |
$78.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.50
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.50
|
| Rate for Payer: University Health Alliance Commercial |
$35.46
|
|
|
FK506 (Prograf) FSI
|
Facility
|
IP
|
$157.00
|
|
|
Service Code
|
HCPCS 80197
|
| Hospital Charge Code |
8228868
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$133.45 |
| Max. Negotiated Rate |
$152.29 |
| Rate for Payer: Cash Price |
$102.05
|
| Rate for Payer: Health Management Network Commercial |
$133.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.30
|
| Rate for Payer: MDX Hawaii PPO |
$152.29
|
|
|
Flu AB PCR Rfx CoV-2 FSI
|
Facility
|
OP
|
$947.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
8860987
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$95.80 |
| Max. Negotiated Rate |
$918.59 |
| Rate for Payer: AlohaCare Medicaid |
$473.50
|
| Rate for Payer: AlohaCare Medicare |
$473.50
|
| Rate for Payer: Cash Price |
$615.55
|
| Rate for Payer: Cash Price |
$615.55
|
| Rate for Payer: Devoted Health Medicare |
$520.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$119.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$119.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$473.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$117.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.80
|
| Rate for Payer: Health Management Network Commercial |
$804.95
|
| Rate for Payer: Humana Medicare |
$473.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$852.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$482.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$473.50
|
| Rate for Payer: MDX Hawaii PPO |
$918.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$473.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$473.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$119.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$473.50
|
| Rate for Payer: University Health Alliance Commercial |
$221.54
|
|
|
Flu AB PCR Rfx CoV-2 FSI
|
Facility
|
IP
|
$947.00
|
|
|
Service Code
|
HCPCS 87502
|
| Hospital Charge Code |
8860987
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$804.95 |
| Max. Negotiated Rate |
$918.59 |
| Rate for Payer: Cash Price |
$615.55
|
| Rate for Payer: Health Management Network Commercial |
$804.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$852.30
|
| Rate for Payer: MDX Hawaii PPO |
$918.59
|
|
|
fluconazole 100 mg tablet [HHSC]
|
Facility
|
OP
|
$118.47
|
|
|
Service Code
|
NDC 68084072801
|
| Hospital Charge Code |
2500327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.23 |
| Max. Negotiated Rate |
$114.92 |
| Rate for Payer: AlohaCare Medicaid |
$59.23
|
| Rate for Payer: AlohaCare Medicare |
$59.23
|
| Rate for Payer: Cash Price |
$77.01
|
| Rate for Payer: Devoted Health Medicare |
$65.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.55
|
| Rate for Payer: Health Management Network Commercial |
$100.70
|
| Rate for Payer: Humana Medicare |
$59.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.23
|
| Rate for Payer: MDX Hawaii PPO |
$114.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.23
|
| Rate for Payer: University Health Alliance Commercial |
$86.35
|
|
|
fluconazole 100 mg tablet [HHSC]
|
Facility
|
IP
|
$118.47
|
|
|
Service Code
|
NDC 68084072801
|
| Hospital Charge Code |
2500327
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.70 |
| Max. Negotiated Rate |
$114.92 |
| Rate for Payer: Cash Price |
$77.01
|
| Rate for Payer: Health Management Network Commercial |
$100.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.62
|
| Rate for Payer: MDX Hawaii PPO |
$114.92
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
IP
|
$76.71
|
|
|
Service Code
|
NDC 68462010340
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.20 |
| Max. Negotiated Rate |
$74.41 |
| Rate for Payer: Cash Price |
$49.86
|
| Rate for Payer: Health Management Network Commercial |
$65.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.04
|
| Rate for Payer: MDX Hawaii PPO |
$74.41
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
IP
|
$76.39
|
|
|
Service Code
|
NDC 57237000511
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.93 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: Cash Price |
$49.65
|
| Rate for Payer: Health Management Network Commercial |
$64.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.75
|
| Rate for Payer: MDX Hawaii PPO |
$74.10
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
IP
|
$76.71
|
|
|
Service Code
|
NDC 68001025317
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.20 |
| Max. Negotiated Rate |
$74.41 |
| Rate for Payer: Cash Price |
$49.86
|
| Rate for Payer: Health Management Network Commercial |
$65.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.04
|
| Rate for Payer: MDX Hawaii PPO |
$74.41
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
OP
|
$76.39
|
|
|
Service Code
|
NDC 57237000511
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.20 |
| Max. Negotiated Rate |
$74.10 |
| Rate for Payer: AlohaCare Medicaid |
$38.20
|
| Rate for Payer: AlohaCare Medicare |
$38.20
|
| Rate for Payer: Cash Price |
$49.65
|
| Rate for Payer: Devoted Health Medicare |
$42.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.57
|
| Rate for Payer: Health Management Network Commercial |
$64.93
|
| Rate for Payer: Humana Medicare |
$38.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.20
|
| Rate for Payer: MDX Hawaii PPO |
$74.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.20
|
| Rate for Payer: University Health Alliance Commercial |
$55.68
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
OP
|
$76.71
|
|
|
Service Code
|
NDC 68001025317
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$74.41 |
| Rate for Payer: AlohaCare Medicaid |
$38.35
|
| Rate for Payer: AlohaCare Medicare |
$38.35
|
| Rate for Payer: Cash Price |
$49.86
|
| Rate for Payer: Devoted Health Medicare |
$42.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.87
|
| Rate for Payer: Health Management Network Commercial |
$65.20
|
| Rate for Payer: Humana Medicare |
$38.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.35
|
| Rate for Payer: MDX Hawaii PPO |
$74.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.35
|
| Rate for Payer: University Health Alliance Commercial |
$55.91
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
OP
|
$76.71
|
|
|
Service Code
|
NDC 68462010340
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$74.41 |
| Rate for Payer: Cash Price |
$49.86
|
| Rate for Payer: AlohaCare Medicaid |
$38.35
|
| Rate for Payer: AlohaCare Medicare |
$38.35
|
| Rate for Payer: Devoted Health Medicare |
$42.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.87
|
| Rate for Payer: Health Management Network Commercial |
$65.20
|
| Rate for Payer: Humana Medicare |
$38.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.35
|
| Rate for Payer: MDX Hawaii PPO |
$74.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.35
|
| Rate for Payer: University Health Alliance Commercial |
$55.91
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
IP
|
$76.71
|
|
|
Service Code
|
NDC 68001025320
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.20 |
| Max. Negotiated Rate |
$74.41 |
| Rate for Payer: Cash Price |
$49.86
|
| Rate for Payer: Health Management Network Commercial |
$65.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.04
|
| Rate for Payer: MDX Hawaii PPO |
$74.41
|
|
|
fluconazole 150 mg tablet [HHSC]
|
Facility
|
OP
|
$76.71
|
|
|
Service Code
|
NDC 68001025320
|
| Hospital Charge Code |
2500329
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.35 |
| Max. Negotiated Rate |
$74.41 |
| Rate for Payer: AlohaCare Medicaid |
$38.35
|
| Rate for Payer: AlohaCare Medicare |
$38.35
|
| Rate for Payer: Cash Price |
$49.86
|
| Rate for Payer: Devoted Health Medicare |
$42.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.87
|
| Rate for Payer: Health Management Network Commercial |
$65.20
|
| Rate for Payer: Humana Medicare |
$38.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.35
|
| Rate for Payer: MDX Hawaii PPO |
$74.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.35
|
| Rate for Payer: University Health Alliance Commercial |
$55.91
|
|
|
fluconazole-ns 200 mg/100 ml premix [HHSC]
|
Facility
|
IP
|
$30.02
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
2500330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.52 |
| Max. Negotiated Rate |
$29.12 |
| Rate for Payer: Cash Price |
$19.51
|
| Rate for Payer: Cash Price |
$40.48
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Health Management Network Commercial |
$22.72
|
| Rate for Payer: Health Management Network Commercial |
$52.94
|
| Rate for Payer: Health Management Network Commercial |
$25.52
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.02
|
| Rate for Payer: MDX Hawaii PPO |
$60.41
|
| Rate for Payer: MDX Hawaii PPO |
$25.93
|
| Rate for Payer: MDX Hawaii PPO |
$29.12
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
|
|
fluconazole-ns 200 mg/100 ml premix [HHSC]
|
Facility
|
OP
|
$30.02
|
|
|
Service Code
|
HCPCS J1450
|
| Hospital Charge Code |
2500330
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$29.12 |
| Rate for Payer: AlohaCare Medicaid |
$15.01
|
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicaid |
$13.37
|
| Rate for Payer: AlohaCare Medicaid |
$31.14
|
| Rate for Payer: AlohaCare Medicare |
$31.14
|
| Rate for Payer: AlohaCare Medicare |
$13.37
|
| Rate for Payer: AlohaCare Medicare |
$15.01
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: Cash Price |
$40.48
|
| Rate for Payer: Cash Price |
$19.51
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$40.48
|
| Rate for Payer: Cash Price |
$17.37
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$19.51
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$16.51
|
| Rate for Payer: Devoted Health Medicare |
$34.25
|
| Rate for Payer: Devoted Health Medicare |
$14.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$59.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.52
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$22.72
|
| Rate for Payer: Health Management Network Commercial |
$25.52
|
| Rate for Payer: Health Management Network Commercial |
$52.94
|
| Rate for Payer: Humana Medicare |
$13.37
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$15.01
|
| Rate for Payer: Humana Medicare |
$31.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.01
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.93
|
| Rate for Payer: MDX Hawaii PPO |
$60.41
|
| Rate for Payer: MDX Hawaii PPO |
$29.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.01
|
| Rate for Payer: University Health Alliance Commercial |
$19.48
|
| Rate for Payer: University Health Alliance Commercial |
$21.88
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$45.40
|
|
|
fludrocortisone 0.1 mg tablet [HHSC]
|
Facility
|
OP
|
$4.11
|
|
|
Service Code
|
NDC 00115703301
|
| Hospital Charge Code |
2500331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: AlohaCare Medicaid |
$2.06
|
| Rate for Payer: AlohaCare Medicare |
$2.06
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Devoted Health Medicare |
$2.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.90
|
| Rate for Payer: Health Management Network Commercial |
$3.49
|
| Rate for Payer: Humana Medicare |
$2.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.06
|
| Rate for Payer: MDX Hawaii PPO |
$3.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.06
|
| Rate for Payer: University Health Alliance Commercial |
$3.00
|
|
|
fludrocortisone 0.1 mg tablet [HHSC]
|
Facility
|
IP
|
$4.11
|
|
|
Service Code
|
NDC 00115703301
|
| Hospital Charge Code |
2500331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Health Management Network Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.70
|
| Rate for Payer: MDX Hawaii PPO |
$3.99
|
|
|
fludrocortisone 0.1 mg tablet [HHSC]
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 68084028801
|
| Hospital Charge Code |
2500331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: AlohaCare Medicaid |
$2.23
|
| Rate for Payer: AlohaCare Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Devoted Health Medicare |
$2.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.24
|
| Rate for Payer: Health Management Network Commercial |
$3.79
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.23
|
| Rate for Payer: MDX Hawaii PPO |
$4.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.23
|
| Rate for Payer: University Health Alliance Commercial |
$3.25
|
|
|
fludrocortisone 0.1 mg tablet [HHSC]
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 68084028801
|
| Hospital Charge Code |
2500331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.79 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Cash Price |
$2.90
|
| Rate for Payer: Health Management Network Commercial |
$3.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.01
|
| Rate for Payer: MDX Hawaii PPO |
$4.33
|
|
|
fludrocortisone 0.1 mg tablet [HHSC]
|
Facility
|
OP
|
$8.88
|
|
|
Service Code
|
NDC 50268033015
|
| Hospital Charge Code |
2500331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: AlohaCare Medicaid |
$4.44
|
| Rate for Payer: AlohaCare Medicare |
$4.44
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Devoted Health Medicare |
$4.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.44
|
| Rate for Payer: Health Management Network Commercial |
$7.55
|
| Rate for Payer: Humana Medicare |
$4.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.44
|
| Rate for Payer: MDX Hawaii PPO |
$8.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.44
|
| Rate for Payer: University Health Alliance Commercial |
$6.47
|
|
|
fludrocortisone 0.1 mg tablet [HHSC]
|
Facility
|
IP
|
$8.88
|
|
|
Service Code
|
NDC 50268033015
|
| Hospital Charge Code |
2500331
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.55 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Health Management Network Commercial |
$7.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.99
|
| Rate for Payer: MDX Hawaii PPO |
$8.61
|
|
|
Fluid Cell Count, Diff, Crystals FSI
|
Facility
|
OP
|
$124.00
|
|
|
Service Code
|
HCPCS 89060
|
| Hospital Charge Code |
8117879
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$7.33 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: AlohaCare Medicaid |
$62.00
|
| Rate for Payer: AlohaCare Medicare |
$62.00
|
| Rate for Payer: Cash Price |
$80.60
|
| Rate for Payer: Cash Price |
$80.60
|
| Rate for Payer: Devoted Health Medicare |
$68.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$9.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$9.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.33
|
| Rate for Payer: Health Management Network Commercial |
$105.40
|
| Rate for Payer: Humana Medicare |
$62.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$111.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.00
|
| Rate for Payer: MDX Hawaii PPO |
$120.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.48
|
|
