|
Geminus Volar Distal Radius Plate Stnd 3H Lt GMNLTS3HL [3642909]
|
Facility
|
OP
|
$4,634.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3642909
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,363.34 |
| Max. Negotiated Rate |
$4,494.98 |
| Rate for Payer: Cash Price |
$3,012.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,243.80
|
| Rate for Payer: Health Management Network Commercial |
$3,938.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,919.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,363.34
|
| Rate for Payer: MDX Hawaii PPO |
$4,494.98
|
| Rate for Payer: University Health Alliance Commercial |
$2,595.04
|
|
|
Geminus Volar Distal Radius Plate Stnd 3H Rt GMNRTS3HL [3643445]
|
Facility
|
IP
|
$4,841.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,710.96 |
| Max. Negotiated Rate |
$4,695.77 |
| Rate for Payer: Cash Price |
$3,146.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.70
|
| Rate for Payer: Health Management Network Commercial |
$4,114.85
|
| Rate for Payer: MDX Hawaii PPO |
$4,695.77
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.96
|
|
|
Geminus Volar Distal Radius Plate Stnd 3H Rt GMNRTS3HL [3643445]
|
Facility
|
OP
|
$4,841.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,468.91 |
| Max. Negotiated Rate |
$4,695.77 |
| Rate for Payer: Cash Price |
$3,146.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,388.70
|
| Rate for Payer: Health Management Network Commercial |
$4,114.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,049.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,468.91
|
| Rate for Payer: MDX Hawaii PPO |
$4,695.77
|
| Rate for Payer: University Health Alliance Commercial |
$2,710.96
|
|
|
Geminus Volar Distal Radius Plate Stnd 4h Lt GMN-LTS-4HL [3644276]
|
Facility
|
IP
|
$4,818.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3644276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,698.36 |
| Max. Negotiated Rate |
$4,673.94 |
| Rate for Payer: Cash Price |
$3,132.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,372.95
|
| Rate for Payer: Health Management Network Commercial |
$4,095.72
|
| Rate for Payer: MDX Hawaii PPO |
$4,673.94
|
| Rate for Payer: University Health Alliance Commercial |
$2,698.36
|
|
|
Geminus Volar Distal Radius Plate Stnd 4h Lt GMN-LTS-4HL [3644276]
|
Facility
|
OP
|
$4,818.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3644276
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,457.43 |
| Max. Negotiated Rate |
$4,673.94 |
| Rate for Payer: Cash Price |
$3,132.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,372.95
|
| Rate for Payer: Health Management Network Commercial |
$4,095.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,035.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,457.43
|
| Rate for Payer: MDX Hawaii PPO |
$4,673.94
|
| Rate for Payer: University Health Alliance Commercial |
$2,698.36
|
|
|
Geminus Volar Distal Radius Plate Wide 4H Lt GMN-LTW-4HL [3643184]
|
Facility
|
OP
|
$5,052.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3643184
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,576.52 |
| Max. Negotiated Rate |
$4,900.44 |
| Rate for Payer: Cash Price |
$3,283.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,536.40
|
| Rate for Payer: Health Management Network Commercial |
$4,294.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,182.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,576.52
|
| Rate for Payer: MDX Hawaii PPO |
$4,900.44
|
| Rate for Payer: University Health Alliance Commercial |
$2,829.12
|
|
|
Geminus Volar Distal Radius Plate Wide 4H Lt GMN-LTW-4HL [3643184]
|
Facility
|
IP
|
$5,052.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
3643184
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,829.12 |
| Max. Negotiated Rate |
$4,900.44 |
| Rate for Payer: Cash Price |
$3,283.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,536.40
|
| Rate for Payer: Health Management Network Commercial |
$4,294.20
|
| Rate for Payer: MDX Hawaii PPO |
$4,900.44
|
| Rate for Payer: University Health Alliance Commercial |
$2,829.12
|
|
|
GENERAL HEALTH PANEL
|
Professional
|
Both
|
$65.00
|
|
|
Service Code
|
HCPCS 80050
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$55.25 |
| Rate for Payer: AlohaCare Medicaid |
$41.19
|
| Rate for Payer: Cash Price |
$42.25
|
| Rate for Payer: Cash Price |
$42.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.00
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.19
|
|
|
Genex 10cc Kit w/Bead Mold Tray 910-010Z [3643158]
|
Facility
|
OP
|
$20,753.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643158
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,584.03 |
| Max. Negotiated Rate |
$20,130.41 |
| Rate for Payer: Cash Price |
$13,489.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,527.10
|
| Rate for Payer: Health Management Network Commercial |
$17,640.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$13,074.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,584.03
|
| Rate for Payer: MDX Hawaii PPO |
$20,130.41
|
| Rate for Payer: University Health Alliance Commercial |
$11,621.68
|
|
|
Genex 10cc Kit w/Bead Mold Tray 910-010Z [3643158]
|
Facility
|
IP
|
$20,753.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643158
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,621.68 |
| Max. Negotiated Rate |
$20,130.41 |
| Rate for Payer: Cash Price |
$13,489.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14,527.10
|
| Rate for Payer: Health Management Network Commercial |
$17,640.05
|
| Rate for Payer: MDX Hawaii PPO |
$20,130.41
|
| Rate for Payer: University Health Alliance Commercial |
$11,621.68
|
|
|
Genex 5cc Kit W/bead Mold Tray 910-005z [3643836]
|
Facility
|
OP
|
$4,468.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643836
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.06 |
| Max. Negotiated Rate |
$4,334.69 |
| Rate for Payer: Cash Price |
$2,904.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,128.12
|
| Rate for Payer: Health Management Network Commercial |
$3,798.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,815.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,279.06
|
| Rate for Payer: MDX Hawaii PPO |
$4,334.69
|
| Rate for Payer: University Health Alliance Commercial |
$2,502.50
|
|
|
Genex 5cc Kit W/bead Mold Tray 910-005z [3643836]
|
Facility
|
IP
|
$4,468.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
3643836
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,502.50 |
| Max. Negotiated Rate |
$4,334.69 |
| Rate for Payer: Cash Price |
$2,904.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,128.12
|
| Rate for Payer: Health Management Network Commercial |
$3,798.44
|
| Rate for Payer: MDX Hawaii PPO |
$4,334.69
|
| Rate for Payer: University Health Alliance Commercial |
$2,502.50
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN
|
Facility
|
OP
|
$155.95
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$151.27 |
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Cash Price |
$16.65
|
| 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 Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.34
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Health Management Network Commercial |
$132.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.07
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
| Rate for Payer: MDX Hawaii PPO |
$151.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.37
|
| Rate for Payer: University Health Alliance Commercial |
$18.67
|
| Rate for Payer: University Health Alliance Commercial |
$113.67
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN
|
Facility
|
IP
|
$25.62
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Health Management Network Commercial |
$132.56
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: MDX Hawaii PPO |
$151.27
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
OP
|
$155.95
|
|
|
Service Code
|
NDC 63323001003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.53 |
| Max. Negotiated Rate |
$151.27 |
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.15
|
| Rate for Payer: Health Management Network Commercial |
$132.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.53
|
| Rate for Payer: MDX Hawaii PPO |
$151.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.57
|
| Rate for Payer: University Health Alliance Commercial |
$113.67
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
OP
|
$25.62
|
|
|
Service Code
|
NDC 63323001002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.07 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.34
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.07
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.37
|
| Rate for Payer: University Health Alliance Commercial |
$18.67
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
IP
|
$25.62
|
|
|
Service Code
|
NDC 63323001001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
IP
|
$155.95
|
|
|
Service Code
|
NDC 63323001020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.56 |
| Max. Negotiated Rate |
$151.27 |
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Health Management Network Commercial |
$132.56
|
| Rate for Payer: MDX Hawaii PPO |
$151.27
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
OP
|
$25.62
|
|
|
Service Code
|
NDC 63323001001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.07 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.34
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.07
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.37
|
| Rate for Payer: University Health Alliance Commercial |
$18.67
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
IP
|
$25.62
|
|
|
Service Code
|
NDC 63323001002
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.78 |
| Max. Negotiated Rate |
$24.85 |
| Rate for Payer: Cash Price |
$16.65
|
| Rate for Payer: Health Management Network Commercial |
$21.78
|
| Rate for Payer: MDX Hawaii PPO |
$24.85
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
IP
|
$155.95
|
|
|
Service Code
|
NDC 63323001003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$132.56 |
| Max. Negotiated Rate |
$151.27 |
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Health Management Network Commercial |
$132.56
|
| Rate for Payer: MDX Hawaii PPO |
$151.27
|
|
|
GENTAMICIN 40 MG/ML INJ SOLN FOR NON IV USE WITHOUT ROUNDING
|
Facility
|
OP
|
$155.95
|
|
|
Service Code
|
NDC 63323001020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.53 |
| Max. Negotiated Rate |
$151.27 |
| Rate for Payer: Cash Price |
$101.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.15
|
| Rate for Payer: Health Management Network Commercial |
$132.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.53
|
| Rate for Payer: MDX Hawaii PPO |
$151.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.57
|
| Rate for Payer: University Health Alliance Commercial |
$113.67
|
|
|
GENTAMICIN (BULK) 590 MCG/MG MISC POWD
|
Facility
|
IP
|
$904.17
|
|
|
Service Code
|
NDC 38779063202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$768.54 |
| Max. Negotiated Rate |
$877.04 |
| Rate for Payer: Cash Price |
$587.71
|
| Rate for Payer: Health Management Network Commercial |
$768.54
|
| Rate for Payer: MDX Hawaii PPO |
$877.04
|
|
|
GENTAMICIN (BULK) 590 MCG/MG MISC POWD
|
Facility
|
OP
|
$904.17
|
|
|
Service Code
|
NDC 38779063202
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$461.13 |
| Max. Negotiated Rate |
$877.04 |
| Rate for Payer: Cash Price |
$587.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$858.96
|
| Rate for Payer: Health Management Network Commercial |
$768.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$569.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$461.13
|
| Rate for Payer: MDX Hawaii PPO |
$877.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$542.50
|
| Rate for Payer: University Health Alliance Commercial |
$659.05
|
|
|
GENTAMICIN IN NACL (ISO-OSM) 80 MG/100 ML IV IVPB
|
Facility
|
IP
|
$22.08
|
|
|
Service Code
|
HCPCS J1580
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
|
