|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [3738]
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
NDC 50268041111
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.50 |
| Max. Negotiated Rate |
$35.89 |
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicare |
$28.12
|
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Devoted Health Medicare |
$31.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.15
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Humana Medicare |
$28.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.12
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.12
|
| Rate for Payer: University Health Alliance Commercial |
$26.97
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [3738]
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
NDC 50268041111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.45 |
| Max. Negotiated Rate |
$35.89 |
| Rate for Payer: Cash Price |
$22.20
|
| Rate for Payer: Health Management Network Commercial |
$31.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [3738]
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
NDC 00713050306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$55.29 |
| Rate for Payer: AlohaCare Medicaid |
$28.50
|
| Rate for Payer: AlohaCare Medicare |
$43.32
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Devoted Health Medicare |
$47.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.15
|
| Rate for Payer: Health Management Network Commercial |
$48.45
|
| Rate for Payer: Humana Medicare |
$43.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.32
|
| Rate for Payer: MDX Hawaii PPO |
$55.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.32
|
| Rate for Payer: University Health Alliance Commercial |
$41.55
|
|
|
HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY [3738]
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
NDC 00713050312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$55.29 |
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Health Management Network Commercial |
$48.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.30
|
| Rate for Payer: MDX Hawaii PPO |
$55.29
|
|
|
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS [24385]
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
NDC 51672300701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$282.50 |
| Max. Negotiated Rate |
$548.05 |
| Rate for Payer: AlohaCare Medicaid |
$282.50
|
| Rate for Payer: AlohaCare Medicare |
$429.40
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Devoted Health Medicare |
$474.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$429.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$536.75
|
| Rate for Payer: Health Management Network Commercial |
$480.25
|
| Rate for Payer: Humana Medicare |
$429.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$508.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$288.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$429.40
|
| Rate for Payer: MDX Hawaii PPO |
$548.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$429.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$429.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$429.40
|
| Rate for Payer: University Health Alliance Commercial |
$411.83
|
|
|
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS [24385]
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
NDC 51672300701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$480.25 |
| Max. Negotiated Rate |
$548.05 |
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Health Management Network Commercial |
$480.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$508.50
|
| Rate for Payer: MDX Hawaii PPO |
$548.05
|
|
|
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [204602]
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS J1720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: AlohaCare Medicaid |
$35.50
|
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: AlohaCare Medicare |
$53.96
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$59.64
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Humana Medicare |
$53.96
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.96
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: University Health Alliance Commercial |
$51.75
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
|
|
HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION [204602]
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS J1720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.35 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
|
|
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION [204601]
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS J1720
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.95 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
|
|
HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION [204601]
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS J1720
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$103.79 |
| Rate for Payer: AlohaCare Medicaid |
$53.50
|
| Rate for Payer: AlohaCare Medicaid |
$21.50
|
| Rate for Payer: AlohaCare Medicare |
$32.68
|
| Rate for Payer: AlohaCare Medicare |
$81.32
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Devoted Health Medicare |
$89.88
|
| Rate for Payer: Devoted Health Medicare |
$36.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$21.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$101.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.85
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Health Management Network Commercial |
$90.95
|
| Rate for Payer: Humana Medicare |
$81.32
|
| Rate for Payer: Humana Medicare |
$32.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.68
|
| Rate for Payer: MDX Hawaii PPO |
$103.79
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$64.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.68
|
| Rate for Payer: University Health Alliance Commercial |
$77.99
|
| Rate for Payer: University Health Alliance Commercial |
$31.34
|
|
|
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE [201344]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
HYDROMORPHONE 2 MG/ML INJECTION SYRINGE [201344]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J1171
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
HYDROMORPHONE 2 MG TABLET [3760]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00406324301
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
HYDROMORPHONE 2 MG TABLET [3760]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00406324301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687059001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687059011
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687059011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687059001
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406324401
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406324401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
HYDROMORPHONE 4 MG TABLET [3761]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 42858030225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
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: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
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: Kaiser Permanente Commercial |
$58.50
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
|
|
HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION [116809]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J1170
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: AlohaCare Medicaid |
$32.50
|
| Rate for Payer: AlohaCare Medicare |
$49.40
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Devoted Health Medicare |
$54.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Humana Medicare |
$49.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.40
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.40
|
| Rate for Payer: University Health Alliance Commercial |
$47.38
|
|
