|
GRAFT RTI BIOLOGICS 3MM 453014
|
Facility
|
OP
|
$2,910.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,455.00 |
| Max. Negotiated Rate |
$2,822.70 |
| Rate for Payer: AlohaCare Medicaid |
$1,455.00
|
| Rate for Payer: AlohaCare Medicare |
$2,211.60
|
| Rate for Payer: Cash Price |
$1,746.00
|
| Rate for Payer: Devoted Health Medicare |
$2,444.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,211.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,037.00
|
| Rate for Payer: Health Management Network Commercial |
$2,473.50
|
| Rate for Payer: Humana Medicare |
$2,211.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,619.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,484.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,211.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,822.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,211.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,211.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,211.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,629.60
|
|
|
GRAFT RTI BIOLOGICS 3MM 453014
|
Facility
|
IP
|
$2,910.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.60 |
| Max. Negotiated Rate |
$2,822.70 |
| Rate for Payer: Cash Price |
$1,746.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,037.00
|
| Rate for Payer: Health Management Network Commercial |
$2,473.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,619.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,822.70
|
| Rate for Payer: University Health Alliance Commercial |
$1,629.60
|
|
|
GRAFT STENT40X40X20 TGMR404020
|
Facility
|
IP
|
$40,290.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,562.40 |
| Max. Negotiated Rate |
$39,081.30 |
| Rate for Payer: Cash Price |
$24,174.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28,203.00
|
| Rate for Payer: Health Management Network Commercial |
$34,246.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$36,261.00
|
| Rate for Payer: MDX Hawaii PPO |
$39,081.30
|
| Rate for Payer: University Health Alliance Commercial |
$22,562.40
|
|
|
GRAFT STENT40X40X20 TGMR404020
|
Facility
|
OP
|
$40,290.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$20,145.00 |
| Max. Negotiated Rate |
$39,081.30 |
| Rate for Payer: AlohaCare Medicaid |
$20,145.00
|
| Rate for Payer: AlohaCare Medicare |
$30,620.40
|
| Rate for Payer: Cash Price |
$24,174.00
|
| Rate for Payer: Devoted Health Medicare |
$33,843.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30,620.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28,203.00
|
| Rate for Payer: Health Management Network Commercial |
$34,246.50
|
| Rate for Payer: Humana Medicare |
$30,620.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36,261.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20,547.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$30,620.40
|
| Rate for Payer: MDX Hawaii PPO |
$39,081.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30,620.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$30,620.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$30,620.40
|
| Rate for Payer: University Health Alliance Commercial |
$22,562.40
|
|
|
GRAFT TAPER 16-18X40 SBT1601D
|
Facility
|
OP
|
$2,802.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,401.00 |
| Max. Negotiated Rate |
$2,717.94 |
| Rate for Payer: AlohaCare Medicaid |
$1,401.00
|
| Rate for Payer: AlohaCare Medicare |
$2,129.52
|
| Rate for Payer: Cash Price |
$1,681.20
|
| Rate for Payer: Devoted Health Medicare |
$2,353.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,129.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,961.40
|
| Rate for Payer: Health Management Network Commercial |
$2,381.70
|
| Rate for Payer: Humana Medicare |
$2,129.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,521.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,429.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,129.52
|
| Rate for Payer: MDX Hawaii PPO |
$2,717.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,129.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,129.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,129.52
|
| Rate for Payer: University Health Alliance Commercial |
$1,569.12
|
|
|
GRAFT TAPER 16-18X40 SBT1601D
|
Facility
|
IP
|
$2,802.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.12 |
| Max. Negotiated Rate |
$2,717.94 |
| Rate for Payer: Cash Price |
$1,681.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,961.40
|
| Rate for Payer: Health Management Network Commercial |
$2,381.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,521.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,717.94
|
| Rate for Payer: University Health Alliance Commercial |
$1,569.12
|
|
|
GRAFT TAPERED EPTE V47050L
|
Facility
|
OP
|
$1,785.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$1,731.45 |
| Rate for Payer: AlohaCare Medicaid |
$892.50
|
| Rate for Payer: AlohaCare Medicare |
$1,356.60
|
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Devoted Health Medicare |
$1,499.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,356.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,249.50
|
| Rate for Payer: Health Management Network Commercial |
$1,517.25
|
| Rate for Payer: Humana Medicare |
$1,356.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,606.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$910.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,356.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,731.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,356.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,356.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,356.60
|
| Rate for Payer: University Health Alliance Commercial |
$999.60
|
|
|
GRAFT TAPERED EPTE V47050L
|
Facility
|
IP
|
$1,785.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.60 |
| Max. Negotiated Rate |
$1,731.45 |
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,249.50
|
| Rate for Payer: Health Management Network Commercial |
$1,517.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,606.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,731.45
|
| Rate for Payer: University Health Alliance Commercial |
$999.60
|
|
|
GRAFT VASCULAR ECH060050A
|
Facility
|
OP
|
$3,080.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,540.00 |
| Max. Negotiated Rate |
$2,987.60 |
| Rate for Payer: AlohaCare Medicaid |
$1,540.00
|
| Rate for Payer: AlohaCare Medicare |
$2,340.80
|
| Rate for Payer: Cash Price |
$1,848.00
|
| Rate for Payer: Devoted Health Medicare |
$2,587.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,340.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,156.00
|
| Rate for Payer: Health Management Network Commercial |
$2,618.00
|
| Rate for Payer: Humana Medicare |
$2,340.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,772.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,570.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,340.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,987.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,340.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,340.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,340.80
|
| Rate for Payer: University Health Alliance Commercial |
$1,724.80
|
|
|
GRAFT VASCULAR ECH060050A
|
Facility
|
IP
|
$3,080.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,724.80 |
| Max. Negotiated Rate |
$2,987.60 |
| Rate for Payer: Cash Price |
$1,848.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,156.00
|
| Rate for Payer: Health Management Network Commercial |
$2,618.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,772.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,987.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,724.80
|
|
|
GRASPER MINIGRIP CLTCH PGCC300
|
Facility
|
IP
|
$945.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$803.25 |
| Max. Negotiated Rate |
$916.65 |
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Health Management Network Commercial |
$803.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$850.50
|
| Rate for Payer: MDX Hawaii PPO |
$916.65
|
|
|
GRASPER MINIGRIP CLTCH PGCC300
|
Facility
|
OP
|
$945.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$472.50 |
| Max. Negotiated Rate |
$916.65 |
| Rate for Payer: AlohaCare Medicaid |
$472.50
|
| Rate for Payer: AlohaCare Medicare |
$718.20
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Devoted Health Medicare |
$793.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$718.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$897.75
|
| Rate for Payer: Health Management Network Commercial |
$803.25
|
| Rate for Payer: Humana Medicare |
$718.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$850.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$481.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$718.20
|
| Rate for Payer: MDX Hawaii PPO |
$916.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$718.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$718.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$718.20
|
| Rate for Payer: University Health Alliance Commercial |
$688.81
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
NDC 00713085004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: AlohaCare Medicaid |
$80.00
|
| Rate for Payer: AlohaCare Medicare |
$121.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Devoted Health Medicare |
$134.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$121.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$152.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Humana Medicare |
$121.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$121.60
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$121.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$121.60
|
| Rate for Payer: University Health Alliance Commercial |
$116.62
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
NDC 00713085004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
NDC 69097036108
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: AlohaCare Medicaid |
$78.00
|
| Rate for Payer: AlohaCare Medicare |
$118.56
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Devoted Health Medicare |
$131.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.20
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Humana Medicare |
$118.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.56
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.56
|
| Rate for Payer: University Health Alliance Commercial |
$113.71
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
NDC 69097036108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 69618006854
|
|
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
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00121148810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00121148810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00121148800
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00121148800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69618006854
|
|
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
|
|
|
GUAIFENESIN/CODEINE 100-10 MG/5 ML SOLUTION UDC (ROBITUSSIN AC) (TAKE HOME) [4080363]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080151
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
GUAIFENESIN/CODEINE 100-10 MG/5 ML SOLUTION UDC (ROBITUSSIN AC) (TAKE HOME) [4080363]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080151
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
GUAIFENESIN/DM 100-10 MG/10 ML SYRUP (ROBITUSSIN DM) (118 ML) (TAKE HOME) [4080394]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080182
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
