|
PR EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/VEEG
|
Professional
|
Both
|
$601.54
|
|
|
Service Code
|
HCPCS 95724
|
| Min. Negotiated Rate |
$273.10 |
| Max. Negotiated Rate |
$511.31 |
| Rate for Payer: AlohaCare Medicaid |
$317.52
|
| Rate for Payer: AlohaCare Medicare |
$273.10
|
| Rate for Payer: Cash Price |
$360.92
|
| Rate for Payer: Cash Price |
$360.92
|
| Rate for Payer: Devoted Health Medicare |
$300.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$317.52
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$409.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.10
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$317.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$348.60
|
| Rate for Payer: Health Management Network Commercial |
$511.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$327.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$327.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$317.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$273.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$317.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.10
|
| Rate for Payer: University Health Alliance Commercial |
$386.23
|
|
|
PR EEG COMPLETE STD PHYS/QHP>84 HR W/O VID
|
Professional
|
Both
|
$549.50
|
|
|
Service Code
|
HCPCS 95725
|
| Min. Negotiated Rate |
$247.92 |
| Max. Negotiated Rate |
$467.07 |
| Rate for Payer: AlohaCare Medicaid |
$291.43
|
| Rate for Payer: AlohaCare Medicare |
$247.92
|
| Rate for Payer: Cash Price |
$329.70
|
| Rate for Payer: Cash Price |
$329.70
|
| Rate for Payer: Devoted Health Medicare |
$272.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$291.43
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$371.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$247.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$291.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$318.50
|
| Rate for Payer: Health Management Network Commercial |
$467.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$297.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$297.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$291.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$247.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$291.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$247.92
|
| Rate for Payer: University Health Alliance Commercial |
$350.99
|
|
|
PR EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG
|
Professional
|
Both
|
$767.76
|
|
|
Service Code
|
HCPCS 95726
|
| Min. Negotiated Rate |
$347.19 |
| Max. Negotiated Rate |
$652.60 |
| Rate for Payer: AlohaCare Medicaid |
$406.95
|
| Rate for Payer: AlohaCare Medicare |
$347.19
|
| Rate for Payer: Cash Price |
$460.66
|
| Rate for Payer: Cash Price |
$460.66
|
| Rate for Payer: Devoted Health Medicare |
$381.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$406.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$516.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$347.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$406.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$440.53
|
| Rate for Payer: Health Management Network Commercial |
$652.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$416.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$416.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$416.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$406.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$347.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$406.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$347.19
|
| Rate for Payer: University Health Alliance Commercial |
$490.15
|
|
|
PR EEG EXTENDED MONITORING 61-119 MINUTES
|
Professional
|
Both
|
$1,496.00
|
|
|
Service Code
|
HCPCS 95813
|
| Min. Negotiated Rate |
$107.72 |
| Max. Negotiated Rate |
$1,271.60 |
| Rate for Payer: AlohaCare Medicaid |
$498.26
|
| Rate for Payer: AlohaCare Medicare |
$535.65
|
| Rate for Payer: Cash Price |
$897.60
|
| Rate for Payer: Cash Price |
$897.60
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$535.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.72
|
| Rate for Payer: Health Management Network Commercial |
$1,271.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$642.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$642.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$642.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$498.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$535.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$498.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$535.65
|
|
|
PR EEG EXTENDED MONITORING 61-119 MINUTES
|
Professional
|
Both
|
$1,336.00
|
|
|
Service Code
|
HCPCS 95813 TC
|
| Min. Negotiated Rate |
$107.72 |
| Max. Negotiated Rate |
$1,135.60 |
| Rate for Payer: AlohaCare Medicaid |
$498.26
|
| Rate for Payer: AlohaCare Medicare |
$444.16
|
| Rate for Payer: Cash Price |
$801.60
|
| Rate for Payer: Cash Price |
$801.60
|
| Rate for Payer: Devoted Health Medicare |
$488.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$444.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.72
|
| Rate for Payer: Health Management Network Commercial |
$1,135.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$532.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$532.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$532.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$498.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$444.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$498.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$444.16
|
|
|
PR EEG EXTENDED MONITORING 61-119 MINUTES
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 95813 26
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$498.26 |
| Rate for Payer: AlohaCare Medicaid |
$498.26
|
| Rate for Payer: AlohaCare Medicare |
$91.50
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Devoted Health Medicare |
$100.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$107.72
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$498.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$498.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.50
|
|
|
PR EEG PHYS/QHP 2-12 HR WITHOUT VIDEO
|
Professional
|
Both
|
$197.82
|
|
|
Service Code
|
HCPCS 95717
|
| Min. Negotiated Rate |
$89.49 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: AlohaCare Medicaid |
$106.66
|
| Rate for Payer: AlohaCare Medicare |
$89.49
|
| Rate for Payer: Cash Price |
$118.69
|
| Rate for Payer: Cash Price |
$118.69
|
| Rate for Payer: Devoted Health Medicare |
$98.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$106.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$129.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$106.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.25
|
| Rate for Payer: Health Management Network Commercial |
$168.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$106.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.49
|
| Rate for Payer: University Health Alliance Commercial |
$121.96
|
|
|
PR EEG PHYS/QHP 2-12 HR WITH VEEG
|
Professional
|
Both
|
$248.41
|
|
|
Service Code
|
HCPCS 95718
|
| Min. Negotiated Rate |
$111.95 |
| Max. Negotiated Rate |
$211.15 |
| Rate for Payer: AlohaCare Medicaid |
$135.33
|
| Rate for Payer: AlohaCare Medicare |
$111.95
|
| Rate for Payer: Cash Price |
$149.05
|
| Rate for Payer: Cash Price |
$149.05
|
| Rate for Payer: Devoted Health Medicare |
$123.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$135.33
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$169.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.95
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$135.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.08
|
| Rate for Payer: Health Management Network Commercial |
$211.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$134.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$135.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.95
|
| Rate for Payer: University Health Alliance Commercial |
$162.76
|
|
|
PR EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR WO VID
|
Professional
|
Both
|
$297.34
|
|
|
Service Code
|
HCPCS 95719
|
| Min. Negotiated Rate |
$134.59 |
| Max. Negotiated Rate |
$252.74 |
| Rate for Payer: AlohaCare Medicaid |
$161.72
|
| Rate for Payer: AlohaCare Medicare |
$134.59
|
| Rate for Payer: Cash Price |
$178.40
|
| Rate for Payer: Cash Price |
$178.40
|
| Rate for Payer: Devoted Health Medicare |
$148.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$161.72
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$200.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$134.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$161.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$169.11
|
| Rate for Payer: Health Management Network Commercial |
$252.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$161.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$161.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$161.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$134.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$161.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$134.59
|
| Rate for Payer: University Health Alliance Commercial |
$189.53
|
|
|
PR EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
HCPCS 95720
|
| Min. Negotiated Rate |
$172.40 |
| Max. Negotiated Rate |
$324.70 |
| Rate for Payer: AlohaCare Medicaid |
$208.28
|
| Rate for Payer: AlohaCare Medicare |
$172.40
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Cash Price |
$229.20
|
| Rate for Payer: Devoted Health Medicare |
$189.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$208.28
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$262.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$208.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$223.02
|
| Rate for Payer: Health Management Network Commercial |
$324.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$206.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$206.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$206.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$208.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$208.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.40
|
| Rate for Payer: University Health Alliance Commercial |
$250.25
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687050601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00904700161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687050611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 69097068105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$16.72
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$16.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.72
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.72
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00904700161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687050601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 69097068105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.70 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
PREGABALIN 100 MG CAPSULE [42165]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687050611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 150 MG CAPSULE [42166]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
NDC 65862076290
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
PREGABALIN 150 MG CAPSULE [42166]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687051701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 150 MG CAPSULE [42166]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687051701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 150 MG CAPSULE [42166]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687051711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
PREGABALIN 150 MG CAPSULE [42166]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687051711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PREGABALIN 150 MG CAPSULE [42166]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
NDC 65862076290
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$19.76
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$21.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Humana Medicare |
$19.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.76
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
PREGABALIN 25 MG CAPSULE [42162]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 60687047301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
