|
HALOBETASOL PROPIONATE 0.05 % TOPICAL CREAM [10159]
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
NDC 45802012935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.15 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL CREAM [10159]
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
NDC 00713064015
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$237.15 |
| Max. Negotiated Rate |
$270.63 |
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Health Management Network Commercial |
$237.15
|
| Rate for Payer: MDX Hawaii PPO |
$270.63
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL CREAM [10159]
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
NDC 00713064015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.29 |
| Max. Negotiated Rate |
$270.63 |
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$265.05
|
| Rate for Payer: Health Management Network Commercial |
$237.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$142.29
|
| Rate for Payer: MDX Hawaii PPO |
$270.63
|
| Rate for Payer: University Health Alliance Commercial |
$203.36
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL CREAM [10159]
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
NDC 45802012935
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.89 |
| Max. Negotiated Rate |
$134.83 |
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$132.05
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.89
|
| Rate for Payer: MDX Hawaii PPO |
$134.83
|
| Rate for Payer: University Health Alliance Commercial |
$101.32
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL OINTMENT [10160]
|
Facility
|
OP
|
$758.00
|
|
|
Service Code
|
NDC 70752011904
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$386.58 |
| Max. Negotiated Rate |
$735.26 |
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$720.10
|
| Rate for Payer: Health Management Network Commercial |
$644.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$477.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$386.58
|
| Rate for Payer: MDX Hawaii PPO |
$735.26
|
| Rate for Payer: University Health Alliance Commercial |
$552.51
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL OINTMENT [10160]
|
Facility
|
OP
|
$670.00
|
|
|
Service Code
|
NDC 45802013132
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$341.70 |
| Max. Negotiated Rate |
$649.90 |
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$636.50
|
| Rate for Payer: Health Management Network Commercial |
$569.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$422.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$341.70
|
| Rate for Payer: MDX Hawaii PPO |
$649.90
|
| Rate for Payer: University Health Alliance Commercial |
$488.36
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL OINTMENT [10160]
|
Facility
|
IP
|
$758.00
|
|
|
Service Code
|
NDC 70752011904
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$644.30 |
| Max. Negotiated Rate |
$735.26 |
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Health Management Network Commercial |
$644.30
|
| Rate for Payer: MDX Hawaii PPO |
$735.26
|
|
|
HALOBETASOL PROPIONATE 0.05 % TOPICAL OINTMENT [10160]
|
Facility
|
IP
|
$670.00
|
|
|
Service Code
|
NDC 45802013132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$569.50 |
| Max. Negotiated Rate |
$649.90 |
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Health Management Network Commercial |
$569.50
|
| Rate for Payer: MDX Hawaii PPO |
$649.90
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079073301
|
|
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: MDX Hawaii PPO |
$1.94
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079073320
|
|
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: MDX Hawaii PPO |
$1.94
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079073301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
HALOPERIDOL 0.5 MG TABLET [3578]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079073320
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079073420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00378025701
|
|
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: MDX Hawaii PPO |
$1.94
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904739061
|
|
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: MDX Hawaii PPO |
$2.91
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079073420
|
|
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: MDX Hawaii PPO |
$1.94
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904739061
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HALOPERIDOL 1 MG TABLET [3579]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00378025701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
HALOPERIDOL 5 MG TABLET [3583]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687016111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
HALOPERIDOL 5 MG TABLET [3583]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687016101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
HALOPERIDOL 5 MG TABLET [3583]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687016111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
HALOPERIDOL 5 MG TABLET [3583]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687016101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION [10163]
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS J1631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$76.63 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.05
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.29
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.40
|
| Rate for Payer: University Health Alliance Commercial |
$57.58
|
|
|
HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION [10163]
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS J1631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.15 |
| Max. Negotiated Rate |
$76.63 |
| Rate for Payer: Cash Price |
$47.40
|
| Rate for Payer: Health Management Network Commercial |
$67.15
|
| Rate for Payer: MDX Hawaii PPO |
$76.63
|
|
|
HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE [3585]
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
NDC 00121058104
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.59 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.55
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: University Health Alliance Commercial |
$79.45
|
|
