|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: AlohaCare Medicaid |
$83.50
|
| Rate for Payer: AlohaCare Medicaid |
$41.00
|
| Rate for Payer: AlohaCare Medicare |
$62.32
|
| Rate for Payer: AlohaCare Medicare |
$126.92
|
| 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: Devoted Health Medicare |
$140.28
|
| Rate for Payer: Devoted Health Medicare |
$68.88
|
| 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 Medicare |
$62.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$126.92
|
| 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: Humana Medicare |
$126.92
|
| Rate for Payer: Humana Medicare |
$62.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$126.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.32
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$126.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$126.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.32
|
| Rate for Payer: University Health Alliance Commercial |
$121.73
|
| Rate for Payer: University Health Alliance Commercial |
$59.77
|
|
|
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: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
|
|
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: AlohaCare Medicaid |
$190.50
|
| Rate for Payer: AlohaCare Medicare |
$289.56
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Devoted Health Medicare |
$320.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$289.56
|
| 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: Humana Medicare |
$289.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$194.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$289.56
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$289.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$289.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$228.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$289.56
|
| Rate for Payer: University Health Alliance Commercial |
$277.71
|
|
|
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: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69097082103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
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: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687022411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687022401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| 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: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
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: Kaiser Permanente Commercial |
$8.10
|
| 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 |
$5,500.00 |
| Max. Negotiated Rate |
$10,670.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,500.00
|
| Rate for Payer: AlohaCare Medicare |
$8,360.00
|
| Rate for Payer: Cash Price |
$6,600.00
|
| Rate for Payer: Devoted Health Medicare |
$9,240.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,360.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,700.00
|
| Rate for Payer: Health Management Network Commercial |
$9,350.00
|
| Rate for Payer: Humana Medicare |
$8,360.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,900.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,610.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,360.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,670.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,360.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,360.00
|
| 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: Kaiser Permanente Commercial |
$9,900.00
|
| 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
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 00713068315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.50 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$131.48
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Devoted Health Medicare |
$145.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$131.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$131.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$131.48
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$131.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$131.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$131.48
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
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: Kaiser Permanente Commercial |
$155.70
|
| 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 |
$86.50 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$131.48
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Devoted Health Medicare |
$145.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$131.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$131.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$131.48
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$131.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$131.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$131.48
|
| 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: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
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: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 45802004635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.50 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$131.48
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Devoted Health Medicare |
$145.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$131.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$131.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$131.48
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$131.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$131.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$131.48
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
NDC 61314063305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.60 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
NDC 61314063305
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: AlohaCare Medicaid |
$38.00
|
| Rate for Payer: AlohaCare Medicare |
$57.76
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Devoted Health Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.20
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Humana Medicare |
$57.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.76
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.76
|
| Rate for Payer: University Health Alliance Commercial |
$55.40
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicaid |
$26.50
|
| Rate for Payer: AlohaCare Medicare |
$15.20
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: AlohaCare Medicare |
$12.16
|
| Rate for Payer: AlohaCare Medicare |
$40.28
|
| Rate for Payer: AlohaCare Medicare |
$106.40
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$13.44
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Devoted Health Medicare |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$117.60
|
| Rate for Payer: Devoted Health Medicare |
$44.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$12.16
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Humana Medicare |
$106.40
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Humana Medicare |
$15.20
|
| Rate for Payer: Humana Medicare |
$40.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
| Rate for Payer: University Health Alliance Commercial |
$38.63
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [3425]
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: AlohaCare Medicaid |
$111.50
|
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$19.76
|
| Rate for Payer: AlohaCare Medicare |
$169.48
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$187.32
|
| Rate for Payer: Devoted Health Medicare |
$21.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$211.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$189.55
|
| Rate for Payer: Humana Medicare |
$169.48
|
| Rate for Payer: Humana Medicare |
$19.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$113.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$216.31
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$133.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.76
|
| Rate for Payer: University Health Alliance Commercial |
$162.54
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION [3425]
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$189.55 |
| Max. Negotiated Rate |
$216.31 |
| Rate for Payer: Cash Price |
$133.80
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$189.55
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: MDX Hawaii PPO |
$216.31
|
|
|
GIA 60-3.8 LOADING GIA6038L
|
Facility
|
IP
|
$208.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$176.80 |
| Max. Negotiated Rate |
$201.76 |
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Health Management Network Commercial |
$176.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$187.20
|
| Rate for Payer: MDX Hawaii PPO |
$201.76
|
|
