|
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.00
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [116345]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [121732]
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
NDC 70121171201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$77.60 |
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Health Management Network Commercial |
$68.00
|
| Rate for Payer: MDX Hawaii PPO |
$77.60
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [121732]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
NDC 55150029701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [121732]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 00338955712
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [166233]
|
Facility
|
OP
|
$719.00
|
|
|
Service Code
|
HCPCS J1190
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.09 |
| Max. Negotiated Rate |
$697.43 |
| Rate for Payer: AlohaCare Medicaid |
$49.74
|
| Rate for Payer: AlohaCare Medicare |
$49.74
|
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Devoted Health Medicare |
$54.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$32.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$62.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.74
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$32.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$683.05
|
| Rate for Payer: Health Management Network Commercial |
$611.15
|
| Rate for Payer: Humana Medicare |
$49.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$452.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$366.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.74
|
| Rate for Payer: MDX Hawaii PPO |
$697.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$431.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.74
|
| Rate for Payer: University Health Alliance Commercial |
$524.08
|
|
|
DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [166233]
|
Facility
|
IP
|
$719.00
|
|
|
Service Code
|
HCPCS J1190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$611.15 |
| Max. Negotiated Rate |
$697.43 |
| Rate for Payer: Cash Price |
$431.40
|
| Rate for Payer: Health Management Network Commercial |
$611.15
|
| Rate for Payer: MDX Hawaii PPO |
$697.43
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [15816]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00121127610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [15816]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 24385057826
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [15816]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00121127600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [15816]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00121127610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [15816]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 24385057826
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
| Rate for Payer: University Health Alliance Commercial |
$14.58
|
|
|
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP [15816]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00121127600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9808]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264762320
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9808]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00264762320
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00264752020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00338002302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION [2357]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00264752000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 00338002302
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 00264752000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
DEXTROSE 10 % IV BOLUS [400302]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 00264752020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$19.40 |
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Health Management Network Commercial |
$17.00
|
| Rate for Payer: MDX Hawaii PPO |
$19.40
|
|
