|
GABAPENTIN 600 MG TABLET [25855]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687050711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
GABAPENTIN 600 MG TABLET [25855]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687050701
|
|
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
|
|
|
GABAPENTIN 600 MG TABLET [25855]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687050701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
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
|
|
|
GABAPENTIN 600 MG TABLET [25855]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904682361
|
|
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 800 MG TABLET [25856]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 68001041200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
GABAPENTIN 800 MG TABLET [25856]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 68001041200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
GABAPENTIN 800 MG TABLET [25856]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904710861
|
|
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 800 MG TABLET [25856]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904710861
|
|
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 800 MG TABLET [25856]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 60687051801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
GABAPENTIN 800 MG TABLET [25856]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 60687051801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [188640]
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
HCPCS A9573
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$140.25 |
| Max. Negotiated Rate |
$160.05 |
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$140.25
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
| Rate for Payer: MDX Hawaii PPO |
$160.05
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [188640]
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
HCPCS A9573
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$160.05 |
| Rate for Payer: AlohaCare Medicaid |
$82.50
|
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicaid |
$110.00
|
| Rate for Payer: AlohaCare Medicare |
$68.20
|
| Rate for Payer: AlohaCare Medicare |
$51.15
|
| Rate for Payer: AlohaCare Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Devoted Health Medicare |
$22.44
|
| Rate for Payer: Devoted Health Medicare |
$74.80
|
| Rate for Payer: Devoted Health Medicare |
$56.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$156.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$209.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Health Management Network Commercial |
$140.25
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Humana Medicare |
$68.20
|
| Rate for Payer: Humana Medicare |
$51.15
|
| Rate for Payer: Humana Medicare |
$20.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$148.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$112.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.20
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: MDX Hawaii PPO |
$160.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.46
|
| Rate for Payer: University Health Alliance Commercial |
$160.36
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
| Rate for Payer: University Health Alliance Commercial |
$120.27
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [124929]
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
HCPCS A9575
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$200.60 |
| Max. Negotiated Rate |
$228.92 |
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Health Management Network Commercial |
$200.60
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.40
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: MDX Hawaii PPO |
$228.92
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
|
|
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [124929]
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS A9575
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: AlohaCare Medicaid |
$69.50
|
| Rate for Payer: AlohaCare Medicaid |
$118.00
|
| Rate for Payer: AlohaCare Medicaid |
$88.50
|
| Rate for Payer: AlohaCare Medicare |
$54.87
|
| Rate for Payer: AlohaCare Medicare |
$43.09
|
| Rate for Payer: AlohaCare Medicare |
$73.16
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Devoted Health Medicare |
$47.26
|
| Rate for Payer: Devoted Health Medicare |
$80.24
|
| Rate for Payer: Devoted Health Medicare |
$60.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$224.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$168.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$132.05
|
| Rate for Payer: Health Management Network Commercial |
$200.60
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Health Management Network Commercial |
$150.45
|
| Rate for Payer: Humana Medicare |
$54.87
|
| Rate for Payer: Humana Medicare |
$73.16
|
| Rate for Payer: Humana Medicare |
$43.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$120.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.87
|
| Rate for Payer: MDX Hawaii PPO |
$228.92
|
| Rate for Payer: MDX Hawaii PPO |
$171.69
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.09
|
| Rate for Payer: University Health Alliance Commercial |
$129.02
|
| Rate for Payer: University Health Alliance Commercial |
$101.32
|
| Rate for Payer: University Health Alliance Commercial |
$172.02
|
|
|
GAMMA 3 SYSTEM 3425-1340S
|
Facility
|
IP
|
$6,402.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,585.12 |
| Max. Negotiated Rate |
$6,209.94 |
| Rate for Payer: Cash Price |
$3,841.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,481.40
|
| Rate for Payer: Health Management Network Commercial |
$5,441.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,761.80
|
| Rate for Payer: MDX Hawaii PPO |
$6,209.94
|
| Rate for Payer: University Health Alliance Commercial |
$3,585.12
|
|
|
GAMMA 3 SYSTEM 3425-1340S
|
Facility
|
OP
|
$6,402.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,984.62 |
| Max. Negotiated Rate |
$6,209.94 |
| Rate for Payer: AlohaCare Medicaid |
$3,201.00
|
| Rate for Payer: AlohaCare Medicare |
$1,984.62
|
| Rate for Payer: Cash Price |
$3,841.20
|
| Rate for Payer: Devoted Health Medicare |
$2,176.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,984.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,481.40
|
| Rate for Payer: Health Management Network Commercial |
$5,441.70
|
| Rate for Payer: Humana Medicare |
$1,984.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,761.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,265.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,984.62
|
| Rate for Payer: MDX Hawaii PPO |
$6,209.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,984.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,984.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,984.62
|
| Rate for Payer: University Health Alliance Commercial |
$3,585.12
|
|
|
GAMMA4 LNG NAIL RT 8425-2400S
|
Facility
|
OP
|
$7,092.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,198.52 |
| Max. Negotiated Rate |
$6,879.24 |
| Rate for Payer: AlohaCare Medicaid |
$3,546.00
|
| Rate for Payer: AlohaCare Medicare |
$2,198.52
|
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Devoted Health Medicare |
$2,411.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,198.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,964.40
|
| Rate for Payer: Health Management Network Commercial |
$6,028.20
|
| Rate for Payer: Humana Medicare |
$2,198.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,382.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,616.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,198.52
|
| Rate for Payer: MDX Hawaii PPO |
$6,879.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,198.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,198.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,198.52
|
| Rate for Payer: University Health Alliance Commercial |
$3,971.52
|
|
|
GAMMA4 LNG NAIL RT 8425-2400S
|
Facility
|
IP
|
$7,092.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,971.52 |
| Max. Negotiated Rate |
$6,879.24 |
| Rate for Payer: Cash Price |
$4,255.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,964.40
|
| Rate for Payer: Health Management Network Commercial |
$6,028.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,382.80
|
| Rate for Payer: MDX Hawaii PPO |
$6,879.24
|
| Rate for Payer: University Health Alliance Commercial |
$3,971.52
|
|
|
GAMMAGARD LIQUID 10% INJECTION SOLUTION 10 G/100 ML [4080049]
|
Facility
|
IP
|
$5,239.00
|
|
|
Service Code
|
HCPCS J1569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,453.15 |
| Max. Negotiated Rate |
$5,081.83 |
| Rate for Payer: Cash Price |
$3,143.40
|
| Rate for Payer: Health Management Network Commercial |
$4,453.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,715.10
|
| Rate for Payer: MDX Hawaii PPO |
$5,081.83
|
|
|
GAMMAGARD LIQUID 10% INJECTION SOLUTION 10 G/100 ML [4080049]
|
Facility
|
OP
|
$5,239.00
|
|
|
Service Code
|
HCPCS J1569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$5,081.83 |
| Rate for Payer: AlohaCare Medicaid |
$2,619.50
|
| Rate for Payer: AlohaCare Medicare |
$1,624.09
|
| Rate for Payer: Cash Price |
$3,143.40
|
| Rate for Payer: Cash Price |
$3,143.40
|
| Rate for Payer: Devoted Health Medicare |
$1,781.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$47.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,624.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$47.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,977.05
|
| Rate for Payer: Health Management Network Commercial |
$4,453.15
|
| Rate for Payer: Humana Medicare |
$1,624.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,715.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,671.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,624.09
|
| Rate for Payer: MDX Hawaii PPO |
$5,081.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,624.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,624.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,143.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,624.09
|
| Rate for Payer: University Health Alliance Commercial |
$3,818.71
|
|
|
GAMMAGARD LIQUID 10% INJECTION SOLUTION 5 G/50 ML [4080050]
|
Facility
|
OP
|
$2,620.00
|
|
|
Service Code
|
HCPCS J1569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.80 |
| Max. Negotiated Rate |
$2,541.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,310.00
|
| Rate for Payer: AlohaCare Medicare |
$812.20
|
| Rate for Payer: Cash Price |
$1,572.00
|
| Rate for Payer: Cash Price |
$1,572.00
|
| Rate for Payer: Devoted Health Medicare |
$890.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$47.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$812.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$47.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,489.00
|
| Rate for Payer: Health Management Network Commercial |
$2,227.00
|
| Rate for Payer: Humana Medicare |
$812.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,358.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,336.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$812.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,541.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$812.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$812.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,572.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$812.20
|
| Rate for Payer: University Health Alliance Commercial |
$1,909.72
|
|
|
GAMMAGARD LIQUID 10% INJECTION SOLUTION 5 G/50 ML [4080050]
|
Facility
|
IP
|
$2,620.00
|
|
|
Service Code
|
HCPCS J1569
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,227.00 |
| Max. Negotiated Rate |
$2,541.40 |
| Rate for Payer: Cash Price |
$1,572.00
|
| Rate for Payer: Health Management Network Commercial |
$2,227.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,358.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,541.40
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
HCPCS J1570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.62 |
| Max. Negotiated Rate |
$170.72 |
| Rate for Payer: AlohaCare Medicaid |
$88.00
|
| Rate for Payer: AlohaCare Medicare |
$54.56
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Devoted Health Medicare |
$59.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$39.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$39.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$167.20
|
| Rate for Payer: Health Management Network Commercial |
$149.60
|
| Rate for Payer: Humana Medicare |
$54.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$158.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.56
|
| Rate for Payer: MDX Hawaii PPO |
$170.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$105.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.56
|
| Rate for Payer: University Health Alliance Commercial |
$128.29
|
|
|
GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
HCPCS J1570
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$149.60 |
| Max. Negotiated Rate |
$170.72 |
| Rate for Payer: Cash Price |
$105.60
|
| Rate for Payer: Health Management Network Commercial |
$149.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$158.40
|
| Rate for Payer: MDX Hawaii PPO |
$170.72
|
|
