Kohala Hospital

All Charges

Charge

Type

Setting

Price

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$11.73

Service Code	NDC 00641602725
Hospital Revenue Code	250
Min. Negotiated Rate	$9.97
Max. Negotiated Rate	$11.38
Rate for Payer: Cash Price	$7.62
Rate for Payer: Health Management Network Commercial	$9.97
Rate for Payer: Kaiser Permanente Commercial	$10.56
Rate for Payer: MDX Hawaii PPO	$11.38

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$11.73

Service Code	NDC 00641602725
Hospital Revenue Code	250
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$11.61
Rate for Payer: AlohaCare Medicaid	$5.87
Rate for Payer: AlohaCare Medicare	$10.56
Rate for Payer: Cash Price	$7.62
Rate for Payer: Devoted Health Medicare	$11.61
Rate for Payer: Hawaii Medical Service Association Medicare	$10.56
Rate for Payer: Hawaii Western Management Group Commercial	$11.14
Rate for Payer: Health Management Network Commercial	$9.97
Rate for Payer: Humana Medicare	$10.56
Rate for Payer: Kaiser Permanente Commercial	$10.56
Rate for Payer: Kaiser Permanente Medicaid	$5.98
Rate for Payer: Kaiser Permanente Medicare	$10.56
Rate for Payer: MDX Hawaii PPO	$11.38
Rate for Payer: Ohana Health Plan Medicaid	$10.56
Rate for Payer: Ohana Health Plan Medicare	$10.56
Rate for Payer: UnitedHealthcare Medicaid	$7.04
Rate for Payer: UnitedHealthcare Medicare	$10.56
Rate for Payer: University Health Alliance Commercial	$8.55

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$11.73

Service Code	NDC 00641602701
Hospital Revenue Code	250
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$11.61
Rate for Payer: AlohaCare Medicaid	$5.87
Rate for Payer: AlohaCare Medicare	$10.56
Rate for Payer: Cash Price	$7.62
Rate for Payer: Devoted Health Medicare	$11.61
Rate for Payer: Hawaii Medical Service Association Medicare	$10.56
Rate for Payer: Hawaii Western Management Group Commercial	$11.14
Rate for Payer: Health Management Network Commercial	$9.97
Rate for Payer: Humana Medicare	$10.56
Rate for Payer: Kaiser Permanente Commercial	$10.56
Rate for Payer: Kaiser Permanente Medicaid	$5.98
Rate for Payer: Kaiser Permanente Medicare	$10.56
Rate for Payer: MDX Hawaii PPO	$11.38
Rate for Payer: Ohana Health Plan Medicaid	$10.56
Rate for Payer: Ohana Health Plan Medicare	$10.56
Rate for Payer: UnitedHealthcare Medicaid	$7.04
Rate for Payer: UnitedHealthcare Medicare	$10.56
Rate for Payer: University Health Alliance Commercial	$8.55

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$15.51

Service Code	NDC 00409909422
Hospital Revenue Code	250
Min. Negotiated Rate	$13.18
Max. Negotiated Rate	$15.04
Rate for Payer: Cash Price	$10.08
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Kaiser Permanente Commercial	$13.96
Rate for Payer: MDX Hawaii PPO	$15.04

FENTANYL CITRATE (PF) 50 MCG/ML INTRANASAL 2 ML

Facility

$15.51

Service Code	NDC 00409909412
Hospital Revenue Code	250
Min. Negotiated Rate	$7.75
Max. Negotiated Rate	$15.35
Rate for Payer: AlohaCare Medicaid	$7.75
Rate for Payer: AlohaCare Medicare	$13.96
Rate for Payer: Cash Price	$10.08
Rate for Payer: Devoted Health Medicare	$15.35
Rate for Payer: Hawaii Medical Service Association Medicare	$13.96
Rate for Payer: Hawaii Western Management Group Commercial	$14.73
Rate for Payer: Health Management Network Commercial	$13.18
Rate for Payer: Humana Medicare	$13.96
Rate for Payer: Kaiser Permanente Commercial	$13.96
Rate for Payer: Kaiser Permanente Medicaid	$7.91
Rate for Payer: Kaiser Permanente Medicare	$13.96
Rate for Payer: MDX Hawaii PPO	$15.04
Rate for Payer: Ohana Health Plan Medicaid	$13.96
Rate for Payer: Ohana Health Plan Medicare	$13.96
Rate for Payer: UnitedHealthcare Medicaid	$9.31
Rate for Payer: UnitedHealthcare Medicare	$13.96
Rate for Payer: University Health Alliance Commercial	$11.31

FENTANYL (PF) IN NS 10 MCG/ML NONTITRATING DRIP

Facility

$197.06

Service Code	HCPCS J3010
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$195.09
Rate for Payer: AlohaCare Medicaid	$98.53
Rate for Payer: AlohaCare Medicare	$177.35
Rate for Payer: Cash Price	$128.09
Rate for Payer: Cash Price	$128.09
Rate for Payer: Devoted Health Medicare	$195.09
Rate for Payer: Hawaii Medical Service Association ABD	$0.96
Rate for Payer: Hawaii Medical Service Association Medicare	$177.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.96
Rate for Payer: Hawaii Western Management Group Commercial	$187.21
Rate for Payer: Health Management Network Commercial	$167.50
Rate for Payer: Humana Medicare	$177.35
Rate for Payer: Kaiser Permanente Commercial	$177.35
Rate for Payer: Kaiser Permanente Medicaid	$100.50
Rate for Payer: Kaiser Permanente Medicare	$177.35
Rate for Payer: MDX Hawaii PPO	$191.15
Rate for Payer: Ohana Health Plan Medicaid	$177.35
Rate for Payer: Ohana Health Plan Medicare	$177.35
Rate for Payer: UnitedHealthcare Medicaid	$118.24
Rate for Payer: UnitedHealthcare Medicare	$177.35
Rate for Payer: University Health Alliance Commercial	$143.64

FENTANYL (PF) IN NS 10 MCG/ML NONTITRATING DRIP

Facility

$197.06

Service Code	HCPCS J3010
Hospital Revenue Code	250
Min. Negotiated Rate	$167.50
Max. Negotiated Rate	$191.15
Rate for Payer: Cash Price	$128.09
Rate for Payer: Health Management Network Commercial	$167.50
Rate for Payer: Kaiser Permanente Commercial	$177.35
Rate for Payer: MDX Hawaii PPO	$191.15

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML PO LIQ

Facility

$22.47

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$19.10
Max. Negotiated Rate	$21.80
Rate for Payer: Cash Price	$14.61
Rate for Payer: Health Management Network Commercial	$19.10
Rate for Payer: Kaiser Permanente Commercial	$20.22
Rate for Payer: MDX Hawaii PPO	$21.80

FERROUS SULFATE 300 MG (60 MG IRON)/5 ML PO LIQ

Facility

$22.47

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$22.25
Rate for Payer: AlohaCare Medicaid	$11.23
Rate for Payer: AlohaCare Medicare	$20.22
Rate for Payer: Cash Price	$14.61
Rate for Payer: Devoted Health Medicare	$22.25
Rate for Payer: Hawaii Medical Service Association Medicare	$20.22
Rate for Payer: Hawaii Western Management Group Commercial	$21.35
Rate for Payer: Health Management Network Commercial	$19.10
Rate for Payer: Humana Medicare	$20.22
Rate for Payer: Kaiser Permanente Commercial	$20.22
Rate for Payer: Kaiser Permanente Medicaid	$11.46
Rate for Payer: Kaiser Permanente Medicare	$20.22
Rate for Payer: MDX Hawaii PPO	$21.80
Rate for Payer: Ohana Health Plan Medicaid	$20.22
Rate for Payer: Ohana Health Plan Medicare	$20.22
Rate for Payer: UnitedHealthcare Medicare	$20.22
Rate for Payer: University Health Alliance Commercial	$16.38

FERROUS SULFATE 324 MG (65 MG IRON) PO TAB DR EC

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.16
Rate for Payer: Cash Price	$0.78
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16

FERROUS SULFATE 324 MG (65 MG IRON) PO TAB DR EC

Facility

$1.20

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.19
Rate for Payer: AlohaCare Medicaid	$0.60
Rate for Payer: AlohaCare Medicare	$1.08
Rate for Payer: Cash Price	$0.78
Rate for Payer: Devoted Health Medicare	$1.19
Rate for Payer: Hawaii Medical Service Association Medicare	$1.08
Rate for Payer: Hawaii Western Management Group Commercial	$1.14
Rate for Payer: Health Management Network Commercial	$1.02
Rate for Payer: Humana Medicare	$1.08
Rate for Payer: Kaiser Permanente Commercial	$1.08
Rate for Payer: Kaiser Permanente Medicaid	$0.61
Rate for Payer: Kaiser Permanente Medicare	$1.08
Rate for Payer: MDX Hawaii PPO	$1.16
Rate for Payer: Ohana Health Plan Medicaid	$1.08
Rate for Payer: Ohana Health Plan Medicare	$1.08
Rate for Payer: UnitedHealthcare Medicare	$1.08
Rate for Payer: University Health Alliance Commercial	$0.87

FEVER AND INFLAMMATORY CONDITIONS

Facility

$22,564.30

Service Code	MSDRG 864
Min. Negotiated Rate	$22,564.30
Max. Negotiated Rate	$22,564.30
Rate for Payer: Hawaii Medical Service Association Commercial	$22,564.30

FIDAXOMICIN 200 MG PO TABLET

Facility

$780.28

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$663.24
Max. Negotiated Rate	$756.87
Rate for Payer: Cash Price	$507.18
Rate for Payer: Health Management Network Commercial	$663.24
Rate for Payer: Kaiser Permanente Commercial	$702.25
Rate for Payer: MDX Hawaii PPO	$756.87

FIDAXOMICIN 200 MG PO TABLET

Facility

$780.28

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$390.14
Max. Negotiated Rate	$772.48
Rate for Payer: AlohaCare Medicaid	$390.14
Rate for Payer: AlohaCare Medicare	$702.25
Rate for Payer: Cash Price	$507.18
Rate for Payer: Devoted Health Medicare	$772.48
Rate for Payer: Hawaii Medical Service Association Medicare	$702.25
Rate for Payer: Hawaii Western Management Group Commercial	$741.27
Rate for Payer: Health Management Network Commercial	$663.24
Rate for Payer: Humana Medicare	$702.25
Rate for Payer: Kaiser Permanente Commercial	$702.25
Rate for Payer: Kaiser Permanente Medicaid	$397.94
Rate for Payer: Kaiser Permanente Medicare	$702.25
Rate for Payer: MDX Hawaii PPO	$756.87
Rate for Payer: Ohana Health Plan Medicaid	$702.25
Rate for Payer: Ohana Health Plan Medicare	$702.25
Rate for Payer: UnitedHealthcare Medicare	$702.25
Rate for Payer: University Health Alliance Commercial	$568.75

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYR

Facility

$809.58

Service Code	HCPCS Q5101
Hospital Revenue Code	250
Min. Negotiated Rate	$688.14
Max. Negotiated Rate	$785.29
Rate for Payer: Cash Price	$526.23
Rate for Payer: Health Management Network Commercial	$688.14
Rate for Payer: Kaiser Permanente Commercial	$728.62
Rate for Payer: MDX Hawaii PPO	$785.29

FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYR

Facility

$809.58

Service Code	HCPCS Q5101
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$801.48
Rate for Payer: AlohaCare Medicaid	$404.79
Rate for Payer: AlohaCare Medicare	$728.62
Rate for Payer: Cash Price	$526.23
Rate for Payer: Cash Price	$526.23
Rate for Payer: Devoted Health Medicare	$801.48
Rate for Payer: Hawaii Medical Service Association ABD	$0.37
Rate for Payer: Hawaii Medical Service Association Commercial	$0.44
Rate for Payer: Hawaii Medical Service Association Medicare	$728.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.37
Rate for Payer: Hawaii Western Management Group Commercial	$769.10
Rate for Payer: Health Management Network Commercial	$688.14
Rate for Payer: Humana Medicare	$728.62
Rate for Payer: Kaiser Permanente Commercial	$728.62
Rate for Payer: Kaiser Permanente Medicaid	$412.89
Rate for Payer: Kaiser Permanente Medicare	$728.62
Rate for Payer: MDX Hawaii PPO	$785.29
Rate for Payer: Ohana Health Plan Medicaid	$728.62
Rate for Payer: Ohana Health Plan Medicare	$728.62
Rate for Payer: UnitedHealthcare Medicaid	$485.75
Rate for Payer: UnitedHealthcare Medicare	$728.62
Rate for Payer: University Health Alliance Commercial	$590.10

FINASTERIDE 5 MG PO TABLET

Facility

$5.30

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$5.25
Rate for Payer: AlohaCare Medicaid	$2.65
Rate for Payer: AlohaCare Medicaid	$2.98
Rate for Payer: AlohaCare Medicare	$4.77
Rate for Payer: AlohaCare Medicare	$5.37
Rate for Payer: Cash Price	$3.44
Rate for Payer: Cash Price	$3.88
Rate for Payer: Devoted Health Medicare	$5.25
Rate for Payer: Devoted Health Medicare	$5.91
Rate for Payer: Hawaii Medical Service Association Medicare	$5.37
Rate for Payer: Hawaii Medical Service Association Medicare	$4.77
Rate for Payer: Hawaii Western Management Group Commercial	$5.67
Rate for Payer: Hawaii Western Management Group Commercial	$5.04
Rate for Payer: Health Management Network Commercial	$4.50
Rate for Payer: Health Management Network Commercial	$5.07
Rate for Payer: Humana Medicare	$4.77
Rate for Payer: Humana Medicare	$5.37
Rate for Payer: Kaiser Permanente Commercial	$5.37
Rate for Payer: Kaiser Permanente Commercial	$4.77
Rate for Payer: Kaiser Permanente Medicaid	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$3.04
Rate for Payer: Kaiser Permanente Medicare	$4.77
Rate for Payer: Kaiser Permanente Medicare	$5.37
Rate for Payer: MDX Hawaii PPO	$5.14
Rate for Payer: MDX Hawaii PPO	$5.79
Rate for Payer: Ohana Health Plan Medicaid	$4.77
Rate for Payer: Ohana Health Plan Medicaid	$5.37
Rate for Payer: Ohana Health Plan Medicare	$5.37
Rate for Payer: Ohana Health Plan Medicare	$4.77
Rate for Payer: UnitedHealthcare Medicare	$4.77
Rate for Payer: UnitedHealthcare Medicare	$5.37
Rate for Payer: University Health Alliance Commercial	$3.86
Rate for Payer: University Health Alliance Commercial	$4.35

FINASTERIDE 5 MG PO TABLET

Facility

$5.30

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$5.14
Rate for Payer: Cash Price	$3.44
Rate for Payer: Cash Price	$3.88
Rate for Payer: Health Management Network Commercial	$5.07
Rate for Payer: Health Management Network Commercial	$4.50
Rate for Payer: Kaiser Permanente Commercial	$4.77
Rate for Payer: Kaiser Permanente Commercial	$5.37
Rate for Payer: MDX Hawaii PPO	$5.14
Rate for Payer: MDX Hawaii PPO	$5.79

FLECAINIDE 100 MG PO TABLET

Facility

$19.77

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$9.88
Max. Negotiated Rate	$19.57
Rate for Payer: AlohaCare Medicaid	$9.88
Rate for Payer: AlohaCare Medicare	$17.79
Rate for Payer: Cash Price	$12.85
Rate for Payer: Devoted Health Medicare	$19.57
Rate for Payer: Hawaii Medical Service Association Medicare	$17.79
Rate for Payer: Hawaii Western Management Group Commercial	$18.78
Rate for Payer: Health Management Network Commercial	$16.80
Rate for Payer: Humana Medicare	$17.79
Rate for Payer: Kaiser Permanente Commercial	$17.79
Rate for Payer: Kaiser Permanente Medicaid	$10.08
Rate for Payer: Kaiser Permanente Medicare	$17.79
Rate for Payer: MDX Hawaii PPO	$19.18
Rate for Payer: Ohana Health Plan Medicaid	$17.79
Rate for Payer: Ohana Health Plan Medicare	$17.79
Rate for Payer: UnitedHealthcare Medicare	$17.79
Rate for Payer: University Health Alliance Commercial	$14.41

FLECAINIDE 100 MG PO TABLET

Facility

$19.77

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$19.18
Rate for Payer: Cash Price	$12.85
Rate for Payer: Health Management Network Commercial	$16.80
Rate for Payer: Kaiser Permanente Commercial	$17.79
Rate for Payer: MDX Hawaii PPO	$19.18

FLUCONAZOLE 100 MG PO TABLET

Facility

$51.94

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$44.15
Max. Negotiated Rate	$50.38
Rate for Payer: Cash Price	$33.76
Rate for Payer: Cash Price	$76.28
Rate for Payer: Cash Price	$5.08
Rate for Payer: Health Management Network Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Health Management Network Commercial	$44.15
Rate for Payer: Kaiser Permanente Commercial	$7.04
Rate for Payer: Kaiser Permanente Commercial	$105.62
Rate for Payer: Kaiser Permanente Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$50.38
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: MDX Hawaii PPO	$7.59

FLUCONAZOLE 100 MG PO TABLET

Facility

$117.36

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$58.68
Max. Negotiated Rate	$116.19
Rate for Payer: AlohaCare Medicaid	$58.68
Rate for Payer: AlohaCare Medicaid	$3.91
Rate for Payer: AlohaCare Medicaid	$25.97
Rate for Payer: AlohaCare Medicare	$46.75
Rate for Payer: AlohaCare Medicare	$105.62
Rate for Payer: AlohaCare Medicare	$7.04
Rate for Payer: Cash Price	$5.08
Rate for Payer: Cash Price	$76.28
Rate for Payer: Cash Price	$33.76
Rate for Payer: Devoted Health Medicare	$51.42
Rate for Payer: Devoted Health Medicare	$116.19
Rate for Payer: Devoted Health Medicare	$7.74
Rate for Payer: Hawaii Medical Service Association Medicare	$7.04
Rate for Payer: Hawaii Medical Service Association Medicare	$105.62
Rate for Payer: Hawaii Medical Service Association Medicare	$46.75
Rate for Payer: Hawaii Western Management Group Commercial	$7.43
Rate for Payer: Hawaii Western Management Group Commercial	$111.49
Rate for Payer: Hawaii Western Management Group Commercial	$49.34
Rate for Payer: Health Management Network Commercial	$99.76
Rate for Payer: Health Management Network Commercial	$44.15
Rate for Payer: Health Management Network Commercial	$6.65
Rate for Payer: Humana Medicare	$46.75
Rate for Payer: Humana Medicare	$7.04
Rate for Payer: Humana Medicare	$105.62
Rate for Payer: Kaiser Permanente Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$105.62
Rate for Payer: Kaiser Permanente Commercial	$7.04
Rate for Payer: Kaiser Permanente Medicaid	$3.99
Rate for Payer: Kaiser Permanente Medicaid	$59.85
Rate for Payer: Kaiser Permanente Medicaid	$26.49
Rate for Payer: Kaiser Permanente Medicare	$105.62
Rate for Payer: Kaiser Permanente Medicare	$46.75
Rate for Payer: Kaiser Permanente Medicare	$7.04
Rate for Payer: MDX Hawaii PPO	$113.84
Rate for Payer: MDX Hawaii PPO	$50.38
Rate for Payer: MDX Hawaii PPO	$7.59
Rate for Payer: Ohana Health Plan Medicaid	$46.75
Rate for Payer: Ohana Health Plan Medicaid	$105.62
Rate for Payer: Ohana Health Plan Medicaid	$7.04
Rate for Payer: Ohana Health Plan Medicare	$105.62
Rate for Payer: Ohana Health Plan Medicare	$46.75
Rate for Payer: Ohana Health Plan Medicare	$7.04
Rate for Payer: UnitedHealthcare Medicare	$105.62
Rate for Payer: UnitedHealthcare Medicare	$7.04
Rate for Payer: UnitedHealthcare Medicare	$46.75
Rate for Payer: University Health Alliance Commercial	$37.86
Rate for Payer: University Health Alliance Commercial	$85.54
Rate for Payer: University Health Alliance Commercial	$5.70

FLUCONAZOLE 150 MG PO TABLET

Facility

$76.01

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$64.61
Max. Negotiated Rate	$73.73
Rate for Payer: Cash Price	$49.41
Rate for Payer: Health Management Network Commercial	$64.61
Rate for Payer: Kaiser Permanente Commercial	$68.41
Rate for Payer: MDX Hawaii PPO	$73.73

FLUCONAZOLE 150 MG PO TABLET

Facility

$76.01

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$38.01
Max. Negotiated Rate	$75.25
Rate for Payer: AlohaCare Medicaid	$38.01
Rate for Payer: AlohaCare Medicare	$68.41
Rate for Payer: Cash Price	$49.41
Rate for Payer: Devoted Health Medicare	$75.25
Rate for Payer: Hawaii Medical Service Association Medicare	$68.41
Rate for Payer: Hawaii Western Management Group Commercial	$72.21
Rate for Payer: Health Management Network Commercial	$64.61
Rate for Payer: Humana Medicare	$68.41
Rate for Payer: Kaiser Permanente Commercial	$68.41
Rate for Payer: Kaiser Permanente Medicaid	$38.77
Rate for Payer: Kaiser Permanente Medicare	$68.41
Rate for Payer: MDX Hawaii PPO	$73.73
Rate for Payer: Ohana Health Plan Medicaid	$68.41
Rate for Payer: Ohana Health Plan Medicare	$68.41
Rate for Payer: UnitedHealthcare Medicare	$68.41
Rate for Payer: University Health Alliance Commercial	$55.40

FLUCONAZOLE 200 MG PO TABLET

Facility

$200.16

Service Code	NDC 68084073511
Hospital Revenue Code	637
Min. Negotiated Rate	$100.08
Max. Negotiated Rate	$198.16
Rate for Payer: AlohaCare Medicaid	$100.08
Rate for Payer: AlohaCare Medicare	$180.14
Rate for Payer: Cash Price	$130.10
Rate for Payer: Devoted Health Medicare	$198.16
Rate for Payer: Hawaii Medical Service Association Medicare	$180.14
Rate for Payer: Hawaii Western Management Group Commercial	$190.15
Rate for Payer: Health Management Network Commercial	$170.14
Rate for Payer: Humana Medicare	$180.14
Rate for Payer: Kaiser Permanente Commercial	$180.14
Rate for Payer: Kaiser Permanente Medicaid	$102.08
Rate for Payer: Kaiser Permanente Medicare	$180.14
Rate for Payer: MDX Hawaii PPO	$194.16
Rate for Payer: Ohana Health Plan Medicaid	$180.14
Rate for Payer: Ohana Health Plan Medicare	$180.14
Rate for Payer: UnitedHealthcare Medicare	$180.14
Rate for Payer: University Health Alliance Commercial	$145.90

Know your out-of-pocket cost for care.

All Charges