|
GRAFT MESH PARIETENE 45X30CM
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1781
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$481.60 |
| Max. Negotiated Rate |
$834.20 |
| Rate for Payer: Cash Price |
$516.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$602.00
|
| Rate for Payer: Health Management Network Commercial |
$731.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$774.00
|
| Rate for Payer: MDX Hawaii PPO |
$834.20
|
| Rate for Payer: University Health Alliance Commercial |
$481.60
|
|
|
GRAFT PROPATEN 6X40 H060040A
|
Facility
|
IP
|
$2,242.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,255.52 |
| Max. Negotiated Rate |
$2,174.74 |
| Rate for Payer: Cash Price |
$1,345.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,569.40
|
| Rate for Payer: Health Management Network Commercial |
$1,905.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,017.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,174.74
|
| Rate for Payer: University Health Alliance Commercial |
$1,255.52
|
|
|
GRAFT PROPATEN 6X40 H060040A
|
Facility
|
OP
|
$2,242.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$695.02 |
| Max. Negotiated Rate |
$2,174.74 |
| Rate for Payer: AlohaCare Medicaid |
$1,121.00
|
| Rate for Payer: AlohaCare Medicare |
$695.02
|
| Rate for Payer: Cash Price |
$1,345.20
|
| Rate for Payer: Devoted Health Medicare |
$762.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$695.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,569.40
|
| Rate for Payer: Health Management Network Commercial |
$1,905.70
|
| Rate for Payer: Humana Medicare |
$695.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,017.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,143.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$695.02
|
| Rate for Payer: MDX Hawaii PPO |
$2,174.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$695.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$695.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$695.02
|
| Rate for Payer: University Health Alliance Commercial |
$1,255.52
|
|
|
GRAFT RTI BIOLOGICS 3MM 453014
|
Facility
|
OP
|
$2,910.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$902.10 |
| Max. Negotiated Rate |
$2,822.70 |
| Rate for Payer: AlohaCare Medicaid |
$1,455.00
|
| Rate for Payer: AlohaCare Medicare |
$902.10
|
| Rate for Payer: Cash Price |
$1,746.00
|
| Rate for Payer: Devoted Health Medicare |
$989.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$902.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,037.00
|
| Rate for Payer: Health Management Network Commercial |
$2,473.50
|
| Rate for Payer: Humana Medicare |
$902.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,619.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,484.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$902.10
|
| Rate for Payer: MDX Hawaii PPO |
$2,822.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$902.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$902.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$902.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,629.60
|
|
|
GRAFT RTI BIOLOGICS 3MM 453014
|
Facility
|
IP
|
$2,910.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,629.60 |
| Max. Negotiated Rate |
$2,822.70 |
| Rate for Payer: Cash Price |
$1,746.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,037.00
|
| Rate for Payer: Health Management Network Commercial |
$2,473.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,619.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,822.70
|
| Rate for Payer: University Health Alliance Commercial |
$1,629.60
|
|
|
GRAFT STENT40X40X20 TGMR404020
|
Facility
|
IP
|
$40,290.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$22,562.40 |
| Max. Negotiated Rate |
$39,081.30 |
| Rate for Payer: Cash Price |
$24,174.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28,203.00
|
| Rate for Payer: Health Management Network Commercial |
$34,246.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$36,261.00
|
| Rate for Payer: MDX Hawaii PPO |
$39,081.30
|
| Rate for Payer: University Health Alliance Commercial |
$22,562.40
|
|
|
GRAFT STENT40X40X20 TGMR404020
|
Facility
|
OP
|
$40,290.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,489.90 |
| Max. Negotiated Rate |
$39,081.30 |
| Rate for Payer: AlohaCare Medicaid |
$20,145.00
|
| Rate for Payer: AlohaCare Medicare |
$12,489.90
|
| Rate for Payer: Cash Price |
$24,174.00
|
| Rate for Payer: Devoted Health Medicare |
$13,698.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12,489.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28,203.00
|
| Rate for Payer: Health Management Network Commercial |
$34,246.50
|
| Rate for Payer: Humana Medicare |
$12,489.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$36,261.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20,547.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$12,489.90
|
| Rate for Payer: MDX Hawaii PPO |
$39,081.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12,489.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$12,489.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$12,489.90
|
| Rate for Payer: University Health Alliance Commercial |
$22,562.40
|
|
|
GRAFT TAPER 16-18X40 SBT1601D
|
Facility
|
OP
|
$2,802.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$868.62 |
| Max. Negotiated Rate |
$2,717.94 |
| Rate for Payer: AlohaCare Medicaid |
$1,401.00
|
| Rate for Payer: AlohaCare Medicare |
$868.62
|
| Rate for Payer: Cash Price |
$1,681.20
|
| Rate for Payer: Devoted Health Medicare |
$952.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$868.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,961.40
|
| Rate for Payer: Health Management Network Commercial |
$2,381.70
|
| Rate for Payer: Humana Medicare |
$868.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,521.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,429.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$868.62
|
| Rate for Payer: MDX Hawaii PPO |
$2,717.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$868.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$868.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$868.62
|
| Rate for Payer: University Health Alliance Commercial |
$1,569.12
|
|
|
GRAFT TAPER 16-18X40 SBT1601D
|
Facility
|
IP
|
$2,802.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,569.12 |
| Max. Negotiated Rate |
$2,717.94 |
| Rate for Payer: Cash Price |
$1,681.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,961.40
|
| Rate for Payer: Health Management Network Commercial |
$2,381.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,521.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,717.94
|
| Rate for Payer: University Health Alliance Commercial |
$1,569.12
|
|
|
GRAFT TAPERED EPTE V47050L
|
Facility
|
OP
|
$1,785.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$553.35 |
| Max. Negotiated Rate |
$1,731.45 |
| Rate for Payer: AlohaCare Medicaid |
$892.50
|
| Rate for Payer: AlohaCare Medicare |
$553.35
|
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Devoted Health Medicare |
$606.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$553.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,249.50
|
| Rate for Payer: Health Management Network Commercial |
$1,517.25
|
| Rate for Payer: Humana Medicare |
$553.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,606.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$910.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$553.35
|
| Rate for Payer: MDX Hawaii PPO |
$1,731.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$553.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$553.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$553.35
|
| Rate for Payer: University Health Alliance Commercial |
$999.60
|
|
|
GRAFT TAPERED EPTE V47050L
|
Facility
|
IP
|
$1,785.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.60 |
| Max. Negotiated Rate |
$1,731.45 |
| Rate for Payer: Cash Price |
$1,071.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,249.50
|
| Rate for Payer: Health Management Network Commercial |
$1,517.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,606.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,731.45
|
| Rate for Payer: University Health Alliance Commercial |
$999.60
|
|
|
GRAFT VASCULAR ECH060050A
|
Facility
|
OP
|
$3,080.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$954.80 |
| Max. Negotiated Rate |
$2,987.60 |
| Rate for Payer: AlohaCare Medicaid |
$1,540.00
|
| Rate for Payer: AlohaCare Medicare |
$954.80
|
| Rate for Payer: Cash Price |
$1,848.00
|
| Rate for Payer: Devoted Health Medicare |
$1,047.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$954.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,156.00
|
| Rate for Payer: Health Management Network Commercial |
$2,618.00
|
| Rate for Payer: Humana Medicare |
$954.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,772.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,570.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$954.80
|
| Rate for Payer: MDX Hawaii PPO |
$2,987.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$954.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$954.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$954.80
|
| Rate for Payer: University Health Alliance Commercial |
$1,724.80
|
|
|
GRAFT VASCULAR ECH060050A
|
Facility
|
IP
|
$3,080.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,724.80 |
| Max. Negotiated Rate |
$2,987.60 |
| Rate for Payer: Cash Price |
$1,848.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,156.00
|
| Rate for Payer: Health Management Network Commercial |
$2,618.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,772.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,987.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,724.80
|
|
|
GRASPER MINIGRIP CLTCH PGCC300
|
Facility
|
OP
|
$945.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$916.65 |
| Rate for Payer: AlohaCare Medicaid |
$472.50
|
| Rate for Payer: AlohaCare Medicare |
$292.95
|
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Devoted Health Medicare |
$321.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$292.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$897.75
|
| Rate for Payer: Health Management Network Commercial |
$803.25
|
| Rate for Payer: Humana Medicare |
$292.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$850.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$481.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$292.95
|
| Rate for Payer: MDX Hawaii PPO |
$916.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$292.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$292.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$292.95
|
| Rate for Payer: University Health Alliance Commercial |
$688.81
|
|
|
GRASPER MINIGRIP CLTCH PGCC300
|
Facility
|
IP
|
$945.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$803.25 |
| Max. Negotiated Rate |
$916.65 |
| Rate for Payer: Cash Price |
$567.00
|
| Rate for Payer: Health Management Network Commercial |
$803.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$850.50
|
| Rate for Payer: MDX Hawaii PPO |
$916.65
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
NDC 00713085004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
NDC 69097036108
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.36 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: AlohaCare Medicaid |
$78.00
|
| Rate for Payer: AlohaCare Medicare |
$48.36
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Devoted Health Medicare |
$53.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.20
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Humana Medicare |
$48.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.36
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.36
|
| Rate for Payer: University Health Alliance Commercial |
$113.71
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
NDC 69097036108
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$151.32 |
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Health Management Network Commercial |
$132.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.40
|
| Rate for Payer: MDX Hawaii PPO |
$151.32
|
|
|
GRISEOFULVIN MICROSIZE 125 MG/5 ML ORAL SUSPENSION [10138]
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
NDC 00713085004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.60 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: AlohaCare Medicaid |
$80.00
|
| Rate for Payer: AlohaCare Medicare |
$49.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Devoted Health Medicare |
$54.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$152.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Humana Medicare |
$49.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.60
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.60
|
| Rate for Payer: University Health Alliance Commercial |
$116.62
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 69618006854
|
|
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
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00121148810
|
|
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
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00121148800
|
|
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
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00121148810
|
|
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
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69618006854
|
|
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
|
|
|
GUAIFENESIN 100 MG/5 ML ORAL LIQUID [13748]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00121148800
|
|
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
|
|
