|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687059011
|
|
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
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 42858030225
|
|
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
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 42858030225
|
|
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
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406324401
|
|
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
|
|
|
HYDROMORPHONE (PF) 10 MG/50 ML (0.2 MG/ML) IN 0.9% NACL IV PCA SYRINGE [130244]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 70092111450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [116809]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J1170
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.15
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.00
|
| Rate for Payer: University Health Alliance Commercial |
$47.38
|
|
|
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [116809]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J1170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
|
|
HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.80
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION [116807]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION [111437]
|
Facility
|
IP
|
$1,758.00
|
|
|
Service Code
|
HCPCS J3424
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,494.30 |
| Max. Negotiated Rate |
$1,705.26 |
| Rate for Payer: Cash Price |
$1,054.80
|
| Rate for Payer: Health Management Network Commercial |
$1,494.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,705.26
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00904704606
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 50268041215
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 50268041211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00904704606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 50268041215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
HYDROXYCHLOROQUINE 200 MG TABLET [10235]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 50268041211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084028401
|
|
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
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 49884072401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084028401
|
|
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
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084028411
|
|
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
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 49884072401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
HYDROXYUREA 500 MG CAPSULE [10236]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084028411
|
|
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
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
NDC 62135075047
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$452.37 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$532.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$558.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$452.37
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
NDC 54838050280
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$378.30 |
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$370.50
|
| Rate for Payer: Health Management Network Commercial |
$331.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$245.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$198.90
|
| Rate for Payer: MDX Hawaii PPO |
$378.30
|
| Rate for Payer: University Health Alliance Commercial |
$284.27
|
|
|
HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION [3771]
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
NDC 62135075047
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$532.20
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
