|
GEL THERAHONEY WOUND GEL 1.5
|
Facility
|
OP
|
$66.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Devoted Health Medicare |
$22.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Humana Medicare |
$20.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.46
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.46
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [151139]
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
HCPCS J9196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$224.40 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Health Management Network Commercial |
$359.55
|
| Rate for Payer: Health Management Network Commercial |
$202.30
|
| Rate for Payer: Health Management Network Commercial |
$252.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$380.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$214.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$267.30
|
| Rate for Payer: MDX Hawaii PPO |
$410.31
|
| Rate for Payer: MDX Hawaii PPO |
$230.86
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: MDX Hawaii PPO |
$288.09
|
|
|
GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [151139]
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
HCPCS J9196
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: AlohaCare Medicaid |
$132.00
|
| Rate for Payer: AlohaCare Medicaid |
$148.50
|
| Rate for Payer: AlohaCare Medicaid |
$119.00
|
| Rate for Payer: AlohaCare Medicaid |
$211.50
|
| Rate for Payer: AlohaCare Medicare |
$131.13
|
| Rate for Payer: AlohaCare Medicare |
$73.78
|
| Rate for Payer: AlohaCare Medicare |
$81.84
|
| Rate for Payer: AlohaCare Medicare |
$92.07
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$142.80
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cash Price |
$178.20
|
| Rate for Payer: Devoted Health Medicare |
$100.98
|
| Rate for Payer: Devoted Health Medicare |
$89.76
|
| Rate for Payer: Devoted Health Medicare |
$143.82
|
| Rate for Payer: Devoted Health Medicare |
$80.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$131.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$92.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$401.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$282.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$226.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$250.80
|
| Rate for Payer: Health Management Network Commercial |
$252.45
|
| Rate for Payer: Health Management Network Commercial |
$202.30
|
| Rate for Payer: Health Management Network Commercial |
$224.40
|
| Rate for Payer: Health Management Network Commercial |
$359.55
|
| Rate for Payer: Humana Medicare |
$73.78
|
| Rate for Payer: Humana Medicare |
$92.07
|
| Rate for Payer: Humana Medicare |
$81.84
|
| Rate for Payer: Humana Medicare |
$131.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$267.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$214.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$380.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$151.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$121.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$215.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$92.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$131.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.84
|
| Rate for Payer: MDX Hawaii PPO |
$288.09
|
| Rate for Payer: MDX Hawaii PPO |
$230.86
|
| Rate for Payer: MDX Hawaii PPO |
$410.31
|
| Rate for Payer: MDX Hawaii PPO |
$256.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$92.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$131.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$131.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$92.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$158.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$178.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$142.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$253.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$92.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$131.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.84
|
| Rate for Payer: University Health Alliance Commercial |
$173.48
|
| Rate for Payer: University Health Alliance Commercial |
$192.43
|
| Rate for Payer: University Health Alliance Commercial |
$216.48
|
| Rate for Payer: University Health Alliance Commercial |
$308.32
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: AlohaCare Medicaid |
$83.50
|
| Rate for Payer: AlohaCare Medicaid |
$41.00
|
| Rate for Payer: AlohaCare Medicare |
$25.42
|
| Rate for Payer: AlohaCare Medicare |
$51.77
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Devoted Health Medicare |
$56.78
|
| Rate for Payer: Devoted Health Medicare |
$27.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.77
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.90
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Humana Medicare |
$51.77
|
| Rate for Payer: Humana Medicare |
$25.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.42
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$100.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.42
|
| Rate for Payer: University Health Alliance Commercial |
$121.73
|
| Rate for Payer: University Health Alliance Commercial |
$59.77
|
|
|
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [112787]
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.95 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: Cash Price |
$100.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [112788]
|
Facility
|
OP
|
$381.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.96 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: AlohaCare Medicaid |
$190.50
|
| Rate for Payer: AlohaCare Medicare |
$118.11
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Devoted Health Medicare |
$129.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$118.11
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$361.95
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Humana Medicare |
$118.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$194.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$118.11
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$118.11
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$228.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$118.11
|
| Rate for Payer: University Health Alliance Commercial |
$277.71
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [112788]
|
Facility
|
IP
|
$381.00
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$323.85 |
| Max. Negotiated Rate |
$369.57 |
| Rate for Payer: Cash Price |
$228.60
|
| Rate for Payer: Health Management Network Commercial |
$323.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$342.90
|
| Rate for Payer: MDX Hawaii PPO |
$369.57
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687022411
|
|
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
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687022411
|
|
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
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 69097082103
|
|
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
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69097082103
|
|
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
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687022401
|
|
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
|
|
|
GEMFIBROZIL 600 MG TABLET [3378]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687022401
|
|
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
|
|
|
GENEX BONE GRAFT 910-01Z
|
Facility
|
OP
|
$11,000.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,410.00 |
| Max. Negotiated Rate |
$10,670.00 |
| Rate for Payer: AlohaCare Medicaid |
$5,500.00
|
| Rate for Payer: AlohaCare Medicare |
$3,410.00
|
| Rate for Payer: Cash Price |
$6,600.00
|
| Rate for Payer: Devoted Health Medicare |
$3,740.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,410.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,700.00
|
| Rate for Payer: Health Management Network Commercial |
$9,350.00
|
| Rate for Payer: Humana Medicare |
$3,410.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,900.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,610.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,410.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,670.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,410.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,410.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,410.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,160.00
|
|
|
GENEX BONE GRAFT 910-01Z
|
Facility
|
IP
|
$11,000.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,160.00 |
| Max. Negotiated Rate |
$10,670.00 |
| Rate for Payer: Cash Price |
$6,600.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,700.00
|
| Rate for Payer: Health Management Network Commercial |
$9,350.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,900.00
|
| Rate for Payer: MDX Hawaii PPO |
$10,670.00
|
| Rate for Payer: University Health Alliance Commercial |
$6,160.00
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
NDC 00713068315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
GENTAMICIN 0.1 % TOPICAL CREAM [3423]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 00713068315
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.63 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$53.63
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Devoted Health Medicare |
$58.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$53.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.63
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.63
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
NDC 45802004635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 45802004635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.63 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$53.63
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Devoted Health Medicare |
$58.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$53.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.63
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.63
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
NDC 00713068215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.63 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: AlohaCare Medicaid |
$86.50
|
| Rate for Payer: AlohaCare Medicare |
$53.63
|
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Devoted Health Medicare |
$58.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$164.35
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Humana Medicare |
$53.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$88.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.63
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.63
|
| Rate for Payer: University Health Alliance Commercial |
$126.10
|
|
|
GENTAMICIN 0.1 % TOPICAL OINTMENT [3424]
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
NDC 00713068215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.05 |
| Max. Negotiated Rate |
$167.81 |
| Rate for Payer: Cash Price |
$103.80
|
| Rate for Payer: Health Management Network Commercial |
$147.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$155.70
|
| Rate for Payer: MDX Hawaii PPO |
$167.81
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
NDC 61314063305
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.56 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: AlohaCare Medicaid |
$38.00
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Devoted Health Medicare |
$25.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.20
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$55.40
|
|
|
GENTAMICIN 0.3 % EYE DROPS [3428]
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
NDC 61314063305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.60 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
GENTAMICIN 40 MG/ML INJECTION SOLUTION [3426]
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicaid |
$10.00
|
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicaid |
$26.50
|
| Rate for Payer: AlohaCare Medicare |
$6.20
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: AlohaCare Medicare |
$16.43
|
| Rate for Payer: AlohaCare Medicare |
$43.40
|
| Rate for Payer: AlohaCare Medicare |
$6.51
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Devoted Health Medicare |
$47.60
|
| Rate for Payer: Devoted Health Medicare |
$18.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$133.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Humana Medicare |
$43.40
|
| Rate for Payer: Humana Medicare |
$6.51
|
| Rate for Payer: Humana Medicare |
$6.20
|
| Rate for Payer: Humana Medicare |
$16.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.51
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
| Rate for Payer: University Health Alliance Commercial |
$38.63
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
