|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [134068]
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS J2401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [134068]
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS J2401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.25
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.45
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.00
|
| Rate for Payer: University Health Alliance Commercial |
$69.25
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.38 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$40.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$40.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.40
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS J3230
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.07 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$27.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$60.00
|
| Rate for Payer: University Health Alliance Commercial |
$72.89
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS J3230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 68462086201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.73 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 68462086201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 69238105601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 69238105601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.73 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687031725
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687031725
|
|
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: MDX Hawaii PPO |
$8.73
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687031795
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687031795
|
|
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: MDX Hawaii PPO |
$8.73
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 51079005820
|
|
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: MDX Hawaii PPO |
$8.73
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 51079005820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 94825000000
|
|
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: MDX Hawaii PPO |
$0.97
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 94825000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 11461000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 86311000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 94810000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 94810000000
|
|
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: MDX Hawaii PPO |
$0.97
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 11461000000
|
|
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: MDX Hawaii PPO |
$0.97
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET [13108]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 86311000000
|
|
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: MDX Hawaii PPO |
$0.97
|
|
|
CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE [15636]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 43463000000
|
|
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: MDX Hawaii PPO |
$0.97
|
|
