|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 60687076811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR [37648]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 60687076821
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084011101
|
|
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
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 64980028001
|
|
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
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 64980028001
|
|
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
|
|
|
GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR [37649]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084011101
|
|
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
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [24869]
|
Facility
|
OP
|
$504.00
|
|
|
Service Code
|
HCPCS J1610
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$156.24 |
| Max. Negotiated Rate |
$488.88 |
| Rate for Payer: AlohaCare Medicaid |
$252.00
|
| Rate for Payer: AlohaCare Medicare |
$156.24
|
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Devoted Health Medicare |
$171.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$195.79
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$182.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$156.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$195.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$478.80
|
| Rate for Payer: Health Management Network Commercial |
$428.40
|
| Rate for Payer: Humana Medicare |
$156.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$453.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$257.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$156.24
|
| Rate for Payer: MDX Hawaii PPO |
$488.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$156.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$156.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$302.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$156.24
|
| Rate for Payer: University Health Alliance Commercial |
$367.37
|
|
|
GLUCAGON 1 MG SOLUTION FOR INJECTION [24869]
|
Facility
|
IP
|
$504.00
|
|
|
Service Code
|
HCPCS J1610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$428.40 |
| Max. Negotiated Rate |
$488.88 |
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Health Management Network Commercial |
$428.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$453.60
|
| Rate for Payer: MDX Hawaii PPO |
$488.88
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [129601]
|
Facility
|
OP
|
$455.00
|
|
|
Service Code
|
HCPCS J1611
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.05 |
| Max. Negotiated Rate |
$441.35 |
| Rate for Payer: AlohaCare Medicaid |
$227.50
|
| Rate for Payer: AlohaCare Medicare |
$141.05
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Devoted Health Medicare |
$154.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$144.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$168.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$141.05
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$144.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$432.25
|
| Rate for Payer: Health Management Network Commercial |
$386.75
|
| Rate for Payer: Humana Medicare |
$141.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$409.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$232.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$141.05
|
| Rate for Payer: MDX Hawaii PPO |
$441.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$141.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$141.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$273.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$141.05
|
| Rate for Payer: University Health Alliance Commercial |
$331.65
|
|
|
GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION [129601]
|
Facility
|
IP
|
$455.00
|
|
|
Service Code
|
HCPCS J1611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$386.75 |
| Max. Negotiated Rate |
$441.35 |
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Health Management Network Commercial |
$386.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$409.50
|
| Rate for Payer: MDX Hawaii PPO |
$441.35
|
|
|
GLUCAGON HCL 1 MG SOLUTION FOR INJECTION [170521]
|
Facility
|
IP
|
$504.00
|
|
|
Service Code
|
HCPCS J1611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$428.40 |
| Max. Negotiated Rate |
$488.88 |
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Health Management Network Commercial |
$428.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$453.60
|
| Rate for Payer: MDX Hawaii PPO |
$488.88
|
|
|
GLUCAGON HCL 1 MG SOLUTION FOR INJECTION [170521]
|
Facility
|
OP
|
$504.00
|
|
|
Service Code
|
HCPCS J1611
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$144.88 |
| Max. Negotiated Rate |
$488.88 |
| Rate for Payer: AlohaCare Medicaid |
$252.00
|
| Rate for Payer: AlohaCare Medicare |
$156.24
|
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Cash Price |
$302.40
|
| Rate for Payer: Devoted Health Medicare |
$171.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$144.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$168.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$156.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$144.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$478.80
|
| Rate for Payer: Health Management Network Commercial |
$428.40
|
| Rate for Payer: Humana Medicare |
$156.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$453.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$257.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$156.24
|
| Rate for Payer: MDX Hawaii PPO |
$488.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$156.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$156.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$302.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$156.24
|
| Rate for Payer: University Health Alliance Commercial |
$367.37
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 72241003905
|
|
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
|
|
|
GLYBURIDE 2.5 MG TABLET [10126]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 72241003905
|
|
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
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00093936401
|
|
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
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 72241004005
|
|
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
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00093936401
|
|
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
|
|
|
GLYBURIDE 5 MG TABLET [3489]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 72241004005
|
|
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
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 46122022171
|
|
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
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 42510000000
|
|
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
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 42511000000
|
|
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
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 42510000000
|
|
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
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 46122022171
|
|
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
|
|
|
GLYCERIN (ADULT) RECTAL SUPPOSITORY [41003]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 42511000000
|
|
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
|
|
|
GLYCERIN (CHILD) RECTAL SUPPOSITORY [76974]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 46122022263
|
|
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
|
|
