|
FUROSEMIDE TABLETS (LASIX) 20 MG (TAKE HOME) [4080362]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080150
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
FUROSEMIDE TABLETS (LASIX) 20 MG (TAKE HOME) [4080362]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080150
|
|
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
|
|
|
FUSION CUP 10 HOLE 18MM FC10
|
Facility
|
OP
|
$2,780.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$861.80 |
| Max. Negotiated Rate |
$2,696.60 |
| Rate for Payer: AlohaCare Medicaid |
$1,390.00
|
| Rate for Payer: AlohaCare Medicare |
$861.80
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Devoted Health Medicare |
$945.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$861.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,946.00
|
| Rate for Payer: Health Management Network Commercial |
$2,363.00
|
| Rate for Payer: Humana Medicare |
$861.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,502.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,417.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$861.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,696.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$861.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$861.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$861.80
|
| Rate for Payer: University Health Alliance Commercial |
$1,556.80
|
|
|
FUSION CUP 10 HOLE 18MM FC10
|
Facility
|
IP
|
$2,780.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.80 |
| Max. Negotiated Rate |
$2,696.60 |
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,946.00
|
| Rate for Payer: Health Management Network Commercial |
$2,363.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,502.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,696.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,556.80
|
|
|
FUSION CUP 14MM RMRUFC-14
|
Facility
|
IP
|
$1,211.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,029.35 |
| Max. Negotiated Rate |
$1,174.67 |
| Rate for Payer: Cash Price |
$726.60
|
| Rate for Payer: Health Management Network Commercial |
$1,029.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,089.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,174.67
|
|
|
FUSION CUP 14MM RMRUFC-14
|
Facility
|
OP
|
$1,211.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$375.41 |
| Max. Negotiated Rate |
$1,174.67 |
| Rate for Payer: AlohaCare Medicaid |
$605.50
|
| Rate for Payer: AlohaCare Medicare |
$375.41
|
| Rate for Payer: Cash Price |
$726.60
|
| Rate for Payer: Devoted Health Medicare |
$411.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$375.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,150.45
|
| Rate for Payer: Health Management Network Commercial |
$1,029.35
|
| Rate for Payer: Humana Medicare |
$375.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,089.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$617.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$375.41
|
| Rate for Payer: MDX Hawaii PPO |
$1,174.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$375.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$375.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$375.41
|
| Rate for Payer: University Health Alliance Commercial |
$882.70
|
|
|
GABAPENTIN 100 MG CAPSULE [18309]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687058011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
GABAPENTIN 100 MG CAPSULE [18309]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 65162010110
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
GABAPENTIN 100 MG CAPSULE [18309]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687058001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
GABAPENTIN 100 MG CAPSULE [18309]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 65162010110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
GABAPENTIN 100 MG CAPSULE [18309]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687058011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
GABAPENTIN 100 MG CAPSULE [18309]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687058001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
GABAPENTIN 250 MG/5 ML ORAL SOLUTION [29169]
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
NDC 42192060816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.25 |
| Max. Negotiated Rate |
$557.75 |
| Rate for Payer: AlohaCare Medicaid |
$287.50
|
| Rate for Payer: AlohaCare Medicare |
$178.25
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Devoted Health Medicare |
$195.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$178.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$546.25
|
| Rate for Payer: Health Management Network Commercial |
$488.75
|
| Rate for Payer: Humana Medicare |
$178.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$517.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$293.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$178.25
|
| Rate for Payer: MDX Hawaii PPO |
$557.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$178.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$178.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$178.25
|
| Rate for Payer: University Health Alliance Commercial |
$419.12
|
|
|
GABAPENTIN 250 MG/5 ML ORAL SOLUTION [29169]
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
NDC 42192060816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$488.75 |
| Max. Negotiated Rate |
$557.75 |
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Health Management Network Commercial |
$488.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$517.50
|
| Rate for Payer: MDX Hawaii PPO |
$557.75
|
|
|
GABAPENTIN 300 MG CAPSULE [18308]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687059111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
GABAPENTIN 300 MG CAPSULE [18308]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 60687059111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
GABAPENTIN 300 MG CAPSULE [18308]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 60687059101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
GABAPENTIN 300 MG CAPSULE [18308]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687059101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904666761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687060201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687060211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 60687060201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 60687060211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
GABAPENTIN 400 MG CAPSULE [18307]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904666761
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
GABAPENTIN 600 MG TABLET [25855]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687050711
|
|
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
|
|
