|
DERMATOME BLADE 00-8800-000-10
|
Facility
|
IP
|
$244.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$207.40 |
| Max. Negotiated Rate |
$236.68 |
| Rate for Payer: Cash Price |
$146.40
|
| Rate for Payer: Health Management Network Commercial |
$207.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$219.60
|
| Rate for Payer: MDX Hawaii PPO |
$236.68
|
|
|
DESFLURANE 100 % INHALATION LIQUID [9747]
|
Facility
|
IP
|
$289.00
|
|
|
Service Code
|
NDC 10019064164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$245.65 |
| Max. Negotiated Rate |
$280.33 |
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Health Management Network Commercial |
$245.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$260.10
|
| Rate for Payer: MDX Hawaii PPO |
$280.33
|
|
|
DESFLURANE 100 % INHALATION LIQUID [9747]
|
Facility
|
IP
|
$289.00
|
|
|
Service Code
|
NDC 10019064134
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$245.65 |
| Max. Negotiated Rate |
$280.33 |
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Health Management Network Commercial |
$245.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$260.10
|
| Rate for Payer: MDX Hawaii PPO |
$280.33
|
|
|
DESFLURANE 100 % INHALATION LIQUID [9747]
|
Facility
|
IP
|
$271.00
|
|
|
Service Code
|
NDC 00781617286
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.35 |
| Max. Negotiated Rate |
$262.87 |
| Rate for Payer: Cash Price |
$162.60
|
| Rate for Payer: Health Management Network Commercial |
$230.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.90
|
| Rate for Payer: MDX Hawaii PPO |
$262.87
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 69238105501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 69238105501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 50742011301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
DESIPRAMINE 25 MG TABLET [2286]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 50742011301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 68001057400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
|
|
DESMOPRESSIN 0.1 MG TABLET [16052]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 68001057400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]
|
Facility
|
OP
|
$616.00
|
|
|
Service Code
|
NDC 24208034205
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.96 |
| Max. Negotiated Rate |
$597.52 |
| Rate for Payer: AlohaCare Medicaid |
$308.00
|
| Rate for Payer: AlohaCare Medicare |
$190.96
|
| Rate for Payer: Cash Price |
$369.60
|
| Rate for Payer: Devoted Health Medicare |
$209.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$190.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$585.20
|
| Rate for Payer: Health Management Network Commercial |
$523.60
|
| Rate for Payer: Humana Medicare |
$190.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$554.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$314.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$190.96
|
| Rate for Payer: MDX Hawaii PPO |
$597.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$190.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$190.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$190.96
|
| Rate for Payer: University Health Alliance Commercial |
$449.00
|
|
|
DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY [27770]
|
Facility
|
IP
|
$616.00
|
|
|
Service Code
|
NDC 24208034205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.60 |
| Max. Negotiated Rate |
$597.52 |
| Rate for Payer: Cash Price |
$369.60
|
| Rate for Payer: Health Management Network Commercial |
$523.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$554.40
|
| Rate for Payer: MDX Hawaii PPO |
$597.52
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
|
OP
|
$1,185.00
|
|
|
Service Code
|
HCPCS J2597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$1,149.45 |
| Rate for Payer: AlohaCare Medicaid |
$592.50
|
| Rate for Payer: AlohaCare Medicaid |
$184.00
|
| Rate for Payer: AlohaCare Medicaid |
$57.00
|
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicare |
$139.50
|
| Rate for Payer: AlohaCare Medicare |
$35.34
|
| Rate for Payer: AlohaCare Medicare |
$367.35
|
| Rate for Payer: AlohaCare Medicare |
$114.08
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Devoted Health Medicare |
$125.12
|
| Rate for Payer: Devoted Health Medicare |
$402.90
|
| Rate for Payer: Devoted Health Medicare |
$153.00
|
| Rate for Payer: Devoted Health Medicare |
$38.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$139.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$367.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$349.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,125.75
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$1,007.25
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Humana Medicare |
$35.34
|
| Rate for Payer: Humana Medicare |
$114.08
|
| Rate for Payer: Humana Medicare |
$367.35
|
| Rate for Payer: Humana Medicare |
$139.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,066.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$604.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$187.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$139.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$367.35
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,149.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$367.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$367.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$711.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$220.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$270.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$367.35
|
| Rate for Payer: University Health Alliance Commercial |
$83.09
|
| Rate for Payer: University Health Alliance Commercial |
$863.75
|
| Rate for Payer: University Health Alliance Commercial |
$268.24
|
| Rate for Payer: University Health Alliance Commercial |
$328.00
|
|
|
DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION [9748]
|
Facility
|
IP
|
$1,185.00
|
|
|
Service Code
|
HCPCS J2597
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,007.25 |
| Max. Negotiated Rate |
$1,149.45 |
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$220.80
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$1,007.25
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Health Management Network Commercial |
$312.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,066.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$331.20
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: MDX Hawaii PPO |
$1,149.45
|
| Rate for Payer: MDX Hawaii PPO |
$356.96
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
NDC 51672127001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.24 |
| Max. Negotiated Rate |
$294.88 |
| Rate for Payer: AlohaCare Medicaid |
$152.00
|
| Rate for Payer: AlohaCare Medicare |
$94.24
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Devoted Health Medicare |
$103.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$288.80
|
| Rate for Payer: Health Management Network Commercial |
$258.40
|
| Rate for Payer: Humana Medicare |
$94.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$155.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$94.24
|
| Rate for Payer: MDX Hawaii PPO |
$294.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.24
|
| Rate for Payer: University Health Alliance Commercial |
$221.59
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
NDC 45802049535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.24 |
| Max. Negotiated Rate |
$197.88 |
| Rate for Payer: AlohaCare Medicaid |
$102.00
|
| Rate for Payer: AlohaCare Medicare |
$63.24
|
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Devoted Health Medicare |
$69.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$193.80
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Humana Medicare |
$63.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.24
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.24
|
| Rate for Payer: University Health Alliance Commercial |
$148.70
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
NDC 51672127001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$258.40 |
| Max. Negotiated Rate |
$294.88 |
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Health Management Network Commercial |
$258.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.60
|
| Rate for Payer: MDX Hawaii PPO |
$294.88
|
|
|
DESOXIMETASONE 0.25 % TOPICAL CREAM [2296]
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
NDC 45802049535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$173.40 |
| Max. Negotiated Rate |
$197.88 |
| Rate for Payer: Cash Price |
$122.40
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
|
|
DESOXIMETASONE 0.25 % TOPICAL OINTMENT [9753]
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
NDC 45802049696
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.10 |
| Max. Negotiated Rate |
$203.70 |
| Rate for Payer: AlohaCare Medicaid |
$105.00
|
| Rate for Payer: AlohaCare Medicare |
$65.10
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Devoted Health Medicare |
$71.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$199.50
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: Humana Medicare |
$65.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$107.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.10
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.10
|
| Rate for Payer: University Health Alliance Commercial |
$153.07
|
|
|
DESOXIMETASONE 0.25 % TOPICAL OINTMENT [9753]
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
NDC 45802049696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$203.70 |
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Health Management Network Commercial |
$178.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$189.00
|
| Rate for Payer: MDX Hawaii PPO |
$203.70
|
|
|
DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR [2319]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J8540
|
|
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: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
DEXAMETHASONE 0.5 MG/5 ML ORAL ELIXIR [2319]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J8540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$39.06
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$39.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.06
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.06
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
DEXAMETHASONE 0.5 MG TABLET [2322]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60505624901
|
|
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
|
|
|
DEXAMETHASONE 0.5 MG TABLET [2322]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00054817925
|
|
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
|
|
|
DEXAMETHASONE 40 MG IN 50 ML NS IVPB (SIMPLE) [4080503]
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS J1100
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$34.92 |
| Rate for Payer: AlohaCare Medicaid |
$18.00
|
| Rate for Payer: AlohaCare Medicare |
$11.16
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Devoted Health Medicare |
$12.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$34.20
|
| Rate for Payer: Health Management Network Commercial |
$30.60
|
| Rate for Payer: Humana Medicare |
$11.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.16
|
| Rate for Payer: MDX Hawaii PPO |
$34.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.16
|
| Rate for Payer: University Health Alliance Commercial |
$26.24
|
|
