|
GEL SIZER RND GS10621-440HP
|
Facility
|
OP
|
$844.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.44 |
| Max. Negotiated Rate |
$818.68 |
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$590.80
|
| Rate for Payer: Health Management Network Commercial |
$717.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$531.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$430.44
|
| Rate for Payer: MDX Hawaii PPO |
$818.68
|
| Rate for Payer: University Health Alliance Commercial |
$472.64
|
|
|
GEL SIZER RND GS10621-470HP
|
Facility
|
OP
|
$844.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$430.44 |
| Max. Negotiated Rate |
$818.68 |
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$590.80
|
| Rate for Payer: Health Management Network Commercial |
$717.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$531.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$430.44
|
| Rate for Payer: MDX Hawaii PPO |
$818.68
|
| Rate for Payer: University Health Alliance Commercial |
$472.64
|
|
|
GEL SIZER RND GS10621-470HP
|
Facility
|
IP
|
$844.00
|
|
|
Service Code
|
HCPCS C1789
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$472.64 |
| Max. Negotiated Rate |
$818.68 |
| Rate for Payer: Cash Price |
$506.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$590.80
|
| Rate for Payer: Health Management Network Commercial |
$717.40
|
| Rate for Payer: MDX Hawaii PPO |
$818.68
|
| Rate for Payer: University Health Alliance Commercial |
$472.64
|
|
|
GEL THERAHONEY WOUND GEL 1.5
|
Facility
|
IP
|
$66.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
GEL THERAHONEY WOUND GEL 1.5
|
Facility
|
OP
|
$66.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.66 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [151139]
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS J9196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Health Management Network Commercial |
$202.30
|
| Rate for Payer: Health Management Network Commercial |
$359.55
|
| Rate for Payer: Health Management Network Commercial |
$252.45
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: MDX Hawaii PPO |
$288.09
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: MDX Hawaii PPO |
$230.86
|
| Rate for Payer: MDX Hawaii PPO |
$410.31
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [151139]
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS J9196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$250.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$282.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$401.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$226.10
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Health Management Network Commercial |
$202.30
|
| Rate for Payer: Health Management Network Commercial |
$252.45
|
| Rate for Payer: Health Management Network Commercial |
$359.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$166.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$266.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$187.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$215.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$151.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$121.38
|
| Rate for Payer: MDX Hawaii PPO |
$230.86
|
| Rate for Payer: MDX Hawaii PPO |
$288.09
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: MDX Hawaii PPO |
$410.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$158.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$253.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$178.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.80
|
| Rate for Payer: University Health Alliance Commercial |
$308.32
|
| Rate for Payer: University Health Alliance Commercial |
$173.48
|
| Rate for Payer: University Health Alliance Commercial |
$192.43
|
| Rate for Payer: University Health Alliance Commercial |
$216.48
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.95 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.90
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.20
|
| Rate for Payer: University Health Alliance Commercial |
$59.77
|
| Rate for Payer: University Health Alliance Commercial |
$121.73
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [112788]
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.85 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [112788]
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.95
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$240.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$194.31
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$228.60
|
| Rate for Payer: University Health Alliance Commercial |
$277.71
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687022411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69097082103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 69097082103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687022401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687022411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687022401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
GENEX BONE GRAFT 910-01Z
|
Facility
|
OP
|
$11,000.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,610.00 |
| Max. Negotiated Rate |
$10,670.00 |
| Rate for Payer: Cash Price |
$6,600.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,700.00
|
| Rate for Payer: Health Management Network Commercial |
$9,350.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,930.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,610.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,670.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,160.00
|
|
|
GENEX BONE GRAFT 910-01Z
|
Facility
|
IP
|
$11,000.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,160.00 |
| Max. Negotiated Rate |
$10,670.00 |
| Rate for Payer: Cash Price |
$6,600.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,700.00
|
| Rate for Payer: Health Management Network Commercial |
$9,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,670.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,160.00
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
NDC 00713068315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 00713068315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 45802004635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
NDC 00713068215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 00713068215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
NDC 45802004635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
