|
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
|
|
|
Fluid Culture FSI
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117912
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
Fluid Culture FSI
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
8117912
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$63.50
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Devoted Health Medicare |
$69.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.62
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$63.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.50
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$22.26
|
|
|
flumazenil 0.5 mg/5ml vial [HHSC]
|
Facility
|
OP
|
$49.27
|
|
|
Service Code
|
NDC 00143978410
|
| Hospital Charge Code |
2500332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$47.79 |
| Rate for Payer: AlohaCare Medicaid |
$24.64
|
| Rate for Payer: AlohaCare Medicare |
$24.64
|
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Devoted Health Medicare |
$27.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.81
|
| Rate for Payer: Health Management Network Commercial |
$41.88
|
| Rate for Payer: Humana Medicare |
$24.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.64
|
| Rate for Payer: MDX Hawaii PPO |
$47.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.64
|
| Rate for Payer: University Health Alliance Commercial |
$35.91
|
|
|
flumazenil 0.5 mg/5ml vial [HHSC]
|
Facility
|
IP
|
$49.27
|
|
|
Service Code
|
NDC 00143978410
|
| Hospital Charge Code |
2500332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.88 |
| Max. Negotiated Rate |
$47.79 |
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Health Management Network Commercial |
$41.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.34
|
| Rate for Payer: MDX Hawaii PPO |
$47.79
|
|
|
flumazenil 0.5 mg/5ml vial [HHSC]
|
Facility
|
IP
|
$47.67
|
|
|
Service Code
|
NDC 00143968410
|
| Hospital Charge Code |
2500332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.52 |
| Max. Negotiated Rate |
$46.24 |
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Health Management Network Commercial |
$40.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.90
|
| Rate for Payer: MDX Hawaii PPO |
$46.24
|
|
|
flumazenil 0.5 mg/5ml vial [HHSC]
|
Facility
|
OP
|
$47.67
|
|
|
Service Code
|
NDC 00143968410
|
| Hospital Charge Code |
2500332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.84 |
| Max. Negotiated Rate |
$46.24 |
| Rate for Payer: AlohaCare Medicaid |
$23.84
|
| Rate for Payer: AlohaCare Medicare |
$23.84
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Devoted Health Medicare |
$26.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.29
|
| Rate for Payer: Health Management Network Commercial |
$40.52
|
| Rate for Payer: Humana Medicare |
$23.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.84
|
| Rate for Payer: MDX Hawaii PPO |
$46.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.84
|
| Rate for Payer: University Health Alliance Commercial |
$34.75
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 17478040401
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 17238090030
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 83851010030
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 83851010030
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 17238090011
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 17238090011
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 17238090030
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
fluorescein ophthalmic 1 mg test [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 17478040401
|
| Hospital Charge Code |
2500334
|
|
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
|
|
|
Fluoroscopic Evaluation of Swallow Function Charge
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
HCPCS 92611 GO,CO
|
| Hospital Charge Code |
8171805
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$387.60 |
| Max. Negotiated Rate |
$442.32 |
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Health Management Network Commercial |
$387.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$410.40
|
| Rate for Payer: MDX Hawaii PPO |
$442.32
|
|
|
Fluoroscopic Evaluation of Swallow Function Charge
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
HCPCS 92611 GO,CO
|
| Hospital Charge Code |
8171805
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$88.36 |
| Max. Negotiated Rate |
$442.32 |
| Rate for Payer: AlohaCare Medicaid |
$228.00
|
| Rate for Payer: AlohaCare Medicare |
$228.00
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Devoted Health Medicare |
$250.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$228.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$433.20
|
| Rate for Payer: Health Management Network Commercial |
$387.60
|
| Rate for Payer: Humana Medicare |
$228.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$410.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$232.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$228.00
|
| Rate for Payer: MDX Hawaii PPO |
$442.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$228.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$228.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$228.00
|
| Rate for Payer: University Health Alliance Commercial |
$255.36
|
|
|
Fluoroscopic Evaluation of Swallow Function Charge
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
HCPCS 92611 GO,CO
|
| Hospital Charge Code |
8177350
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$387.60 |
| Max. Negotiated Rate |
$442.32 |
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Health Management Network Commercial |
$387.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$410.40
|
| Rate for Payer: MDX Hawaii PPO |
$442.32
|
|
|
Fluoroscopic Evaluation of Swallow Function Charge
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
HCPCS 92611 GO,CO
|
| Hospital Charge Code |
8177350
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$88.36 |
| Max. Negotiated Rate |
$442.32 |
| Rate for Payer: AlohaCare Medicaid |
$228.00
|
| Rate for Payer: AlohaCare Medicare |
$228.00
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Devoted Health Medicare |
$250.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$228.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$433.20
|
| Rate for Payer: Health Management Network Commercial |
$387.60
|
| Rate for Payer: Humana Medicare |
$228.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$410.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$232.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$228.00
|
| Rate for Payer: MDX Hawaii PPO |
$442.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$228.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$228.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$88.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$228.00
|
| Rate for Payer: University Health Alliance Commercial |
$255.36
|
|
|
FLUoxetine 20 mg capsule [HHSC]
|
Facility
|
OP
|
$13.98
|
|
|
Service Code
|
NDC 68084060501
|
| Hospital Charge Code |
2500336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$13.56 |
| Rate for Payer: AlohaCare Medicaid |
$6.99
|
| Rate for Payer: AlohaCare Medicare |
$6.99
|
| Rate for Payer: Cash Price |
$9.09
|
| Rate for Payer: Devoted Health Medicare |
$7.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.28
|
| Rate for Payer: Health Management Network Commercial |
$11.88
|
| Rate for Payer: Humana Medicare |
$6.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.99
|
| Rate for Payer: MDX Hawaii PPO |
$13.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.99
|
| Rate for Payer: University Health Alliance Commercial |
$10.19
|
|
|
FLUoxetine 20 mg capsule [HHSC]
|
Facility
|
OP
|
$13.81
|
|
|
Service Code
|
NDC 00904578561
|
| Hospital Charge Code |
2500336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.91 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: AlohaCare Medicaid |
$6.91
|
| Rate for Payer: AlohaCare Medicare |
$6.91
|
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Devoted Health Medicare |
$7.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.12
|
| Rate for Payer: Health Management Network Commercial |
$11.74
|
| Rate for Payer: Humana Medicare |
$6.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.91
|
| Rate for Payer: MDX Hawaii PPO |
$13.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.91
|
| Rate for Payer: University Health Alliance Commercial |
$10.07
|
|
|
FLUoxetine 20 mg capsule [HHSC]
|
Facility
|
IP
|
$13.81
|
|
|
Service Code
|
NDC 00904578561
|
| Hospital Charge Code |
2500336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.74 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: Cash Price |
$8.98
|
| Rate for Payer: Health Management Network Commercial |
$11.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.43
|
| Rate for Payer: MDX Hawaii PPO |
$13.40
|
|
|
FLUoxetine 20 mg capsule [HHSC]
|
Facility
|
OP
|
$14.83
|
|
|
Service Code
|
NDC 68001040000
|
| Hospital Charge Code |
2500336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$14.39 |
| Rate for Payer: AlohaCare Medicaid |
$7.42
|
| Rate for Payer: AlohaCare Medicare |
$7.42
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Devoted Health Medicare |
$8.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.09
|
| Rate for Payer: Health Management Network Commercial |
$12.61
|
| Rate for Payer: Humana Medicare |
$7.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.42
|
| Rate for Payer: MDX Hawaii PPO |
$14.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.42
|
| Rate for Payer: University Health Alliance Commercial |
$10.81
|
|
|
FLUoxetine 20 mg capsule [HHSC]
|
Facility
|
IP
|
$13.98
|
|
|
Service Code
|
NDC 68084060501
|
| Hospital Charge Code |
2500336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$13.56 |
| Rate for Payer: Cash Price |
$9.09
|
| Rate for Payer: Health Management Network Commercial |
$11.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.58
|
| Rate for Payer: MDX Hawaii PPO |
$13.56
|
|
|
FLUoxetine 20 mg capsule [HHSC]
|
Facility
|
IP
|
$14.83
|
|
|
Service Code
|
NDC 68001040000
|
| Hospital Charge Code |
2500336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.61 |
| Max. Negotiated Rate |
$14.39 |
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Health Management Network Commercial |
$12.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.35
|
| Rate for Payer: MDX Hawaii PPO |
$14.39
|
|
