|
glyBURIDE 5 mg Tab [KMC]
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 00093834401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Health Management Network Commercial |
$2.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.80
|
| Rate for Payer: MDX Hawaii PPO |
$3.02
|
|
|
glyBURIDE 5 mg Tab [KMC]
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
NDC 00093834401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: AlohaCare Medicaid |
$1.55
|
| Rate for Payer: AlohaCare Medicare |
$1.31
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2.86
|
| Rate for Payer: Devoted Health Medicare |
$1.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.95
|
| Rate for Payer: Health Management Network Commercial |
$2.64
|
| Rate for Payer: Humana Medicare |
$1.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.31
|
| Rate for Payer: MDX Hawaii PPO |
$3.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.31
|
| Rate for Payer: University Health Alliance Commercial |
$2.27
|
|
|
glycerin adult Supp [KMC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00132007912
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.26
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2.76
|
| Rate for Payer: Devoted Health Medicare |
$1.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.26
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.26
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
glycerin adult Supp [KMC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00132007912
|
|
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
|
|
|
glycopyrrolate 0.2 mg/mL Inj Sol [KMC]
|
Facility
|
OP
|
$7.63
|
|
|
Service Code
|
HCPCS J7642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: AlohaCare Medicaid |
$3.81
|
| Rate for Payer: AlohaCare Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$7.02
|
| Rate for Payer: Devoted Health Medicare |
$3.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.25
|
| Rate for Payer: Health Management Network Commercial |
$6.49
|
| Rate for Payer: Humana Medicare |
$3.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.20
|
| Rate for Payer: University Health Alliance Commercial |
$5.56
|
|
|
glycopyrrolate 0.2 mg/mL Inj Sol [KMC]
|
Facility
|
IP
|
$7.63
|
|
|
Service Code
|
HCPCS J7642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Cash Price |
$4.96
|
| Rate for Payer: Health Management Network Commercial |
$6.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.87
|
| Rate for Payer: MDX Hawaii PPO |
$7.40
|
|
|
Glycopyrrolate 1 mg tab [KMC]
|
Facility
|
OP
|
$525.16
|
|
|
Service Code
|
NDC 64980027201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$220.57 |
| Max. Negotiated Rate |
$509.41 |
| Rate for Payer: AlohaCare Medicaid |
$262.58
|
| Rate for Payer: AlohaCare Medicare |
$220.57
|
| Rate for Payer: Cash Price |
$341.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$483.15
|
| Rate for Payer: Devoted Health Medicare |
$220.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$220.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$498.90
|
| Rate for Payer: Health Management Network Commercial |
$446.39
|
| Rate for Payer: Humana Medicare |
$220.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$267.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$220.57
|
| Rate for Payer: MDX Hawaii PPO |
$509.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$220.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$220.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$315.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$220.57
|
| Rate for Payer: University Health Alliance Commercial |
$382.79
|
|
|
Glycopyrrolate 1 mg tab [KMC]
|
Facility
|
IP
|
$525.16
|
|
|
Service Code
|
NDC 64980027201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$446.39 |
| Max. Negotiated Rate |
$509.41 |
| Rate for Payer: Cash Price |
$341.35
|
| Rate for Payer: Health Management Network Commercial |
$446.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$472.64
|
| Rate for Payer: MDX Hawaii PPO |
$509.41
|
|
|
GONADOTROPIN CHORIONIC QUALITATIVE
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS 84703
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$27.20 |
| Rate for Payer: AlohaCare Medicaid |
$10.38
|
| Rate for Payer: AlohaCare Medicare |
$7.52
|
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Cash Price |
$20.80
|
| Rate for Payer: Devoted Health Medicare |
$7.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.50
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.52
|
|
|
Gram Stain 1
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
422872050
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
Gram Stain 1
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
422872050
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$33.60
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$73.60
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$5.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.27
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$33.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.60
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.60
|
| Rate for Payer: University Health Alliance Commercial |
$11.03
|
|
|
Gram Stain DLS
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
422872055
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
Gram Stain DLS
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
422872055
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: AlohaCare Medicaid |
$40.00
|
| Rate for Payer: AlohaCare Medicare |
$33.60
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$73.60
|
| Rate for Payer: Devoted Health Medicare |
$33.60
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$5.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.27
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: Humana Medicare |
$33.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.60
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.60
|
| Rate for Payer: University Health Alliance Commercial |
$11.03
|
|
|
Group Therapy Charge
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 97150 GP
|
| Hospital Charge Code |
432971500
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
|
|
Group Therapy Charge
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 97150 GP
|
| Hospital Charge Code |
432971500
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$173.63 |
| Rate for Payer: AlohaCare Medicaid |
$89.50
|
| Rate for Payer: AlohaCare Medicare |
$75.18
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Cash Price |
$116.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$164.68
|
| Rate for Payer: Devoted Health Medicare |
$75.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.05
|
| Rate for Payer: Health Management Network Commercial |
$152.15
|
| Rate for Payer: Humana Medicare |
$75.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.18
|
| Rate for Payer: University Health Alliance Commercial |
$130.47
|
|
|
.GTT-1 Hr
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 82950
|
| Hospital Charge Code |
422829500
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.75 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$30.66
|
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$67.16
|
| Rate for Payer: Devoted Health Medicare |
$30.66
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$6.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$30.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.66
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.66
|
| Rate for Payer: University Health Alliance Commercial |
$12.28
|
|
|
.GTT-1 Hr
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 82950
|
| Hospital Charge Code |
422829500
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$47.45
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
.GTT-3 Hr
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 82951
|
| Hospital Charge Code |
422829510
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$97.75 |
| Max. Negotiated Rate |
$111.55 |
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
|
|
.GTT-3 Hr
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 82951
|
| Hospital Charge Code |
422829510
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$111.55 |
| Rate for Payer: AlohaCare Medicaid |
$57.50
|
| Rate for Payer: AlohaCare Medicare |
$48.30
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Cash Price |
$74.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$105.80
|
| Rate for Payer: Devoted Health Medicare |
$48.30
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$17.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.87
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Humana Medicare |
$48.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.30
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.30
|
| Rate for Payer: University Health Alliance Commercial |
$33.28
|
|
|
.GTT Glucose Fasting
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 82947
|
| Hospital Charge Code |
422829470
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$61.20 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Health Management Network Commercial |
$61.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.80
|
| Rate for Payer: MDX Hawaii PPO |
$69.84
|
|
|
.GTT Glucose Fasting
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 82947
|
| Hospital Charge Code |
422829470
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$69.84 |
| Rate for Payer: AlohaCare Medicaid |
$36.00
|
| Rate for Payer: AlohaCare Medicare |
$30.24
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$66.24
|
| Rate for Payer: Devoted Health Medicare |
$30.24
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$5.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.93
|
| Rate for Payer: Health Management Network Commercial |
$61.20
|
| Rate for Payer: Humana Medicare |
$30.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.24
|
| Rate for Payer: MDX Hawaii PPO |
$69.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.24
|
| Rate for Payer: University Health Alliance Commercial |
$10.14
|
|
|
guaiFENesin 100 mg/5 mL Liq [KMC]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 50383006307
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.37 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Health Management Network Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.39
|
| Rate for Payer: MDX Hawaii PPO |
$0.42
|
|
|
guaiFENesin 100 mg/5 mL Liq [KMC]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 50383006307
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: AlohaCare Medicaid |
$0.22
|
| Rate for Payer: AlohaCare Medicare |
$0.18
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$0.40
|
| Rate for Payer: Devoted Health Medicare |
$0.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.41
|
| Rate for Payer: Health Management Network Commercial |
$0.37
|
| Rate for Payer: Humana Medicare |
$0.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.18
|
| Rate for Payer: MDX Hawaii PPO |
$0.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.18
|
| Rate for Payer: University Health Alliance Commercial |
$0.31
|
|
|
guaiFENesin 200 mg/10 mL Liq UD [KMC]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 00121148800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: AlohaCare Medicaid |
$0.13
|
| Rate for Payer: AlohaCare Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$0.23
|
| Rate for Payer: Devoted Health Medicare |
$0.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.24
|
| Rate for Payer: Health Management Network Commercial |
$0.21
|
| Rate for Payer: Humana Medicare |
$0.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.11
|
| Rate for Payer: MDX Hawaii PPO |
$0.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.11
|
| Rate for Payer: University Health Alliance Commercial |
$0.18
|
|
|
guaiFENesin 200 mg/10 mL Liq UD [KMC]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 00121148800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Management Network Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.23
|
| Rate for Payer: MDX Hawaii PPO |
$0.24
|
|
