|
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 00264761600
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$7.75
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$8.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$7.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.75
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9812]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 00264761600
|
|
Hospital Revenue Code
|
258
|
| 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: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00264761200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00264761210
|
|
Hospital Revenue Code
|
258
|
| 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: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00264761210
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9814]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00264761200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J7042
|
|
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: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9815]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J7042
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00264775100
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION [9788]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 00264775100
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J7060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION [2364]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS J7060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicaid |
$5.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$3.41
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$6.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Devoted Health Medicare |
$1.70
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Devoted Health Medicare |
$3.74
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$9.35
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Humana Medicare |
$3.41
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: MDX Hawaii PPO |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$8.02
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$14,932.26
|
|
|
Service Code
|
MSDRG 638
|
| Min. Negotiated Rate |
$14,932.26 |
| Max. Negotiated Rate |
$14,932.26 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,932.26
|
|
|
DIABETES WITH MCC
|
Facility
|
IP
|
$15,074.47
|
|
|
Service Code
|
MSDRG 637
|
| Min. Negotiated Rate |
$15,074.47 |
| Max. Negotiated Rate |
$15,074.47 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15,074.47
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$14,813.75
|
|
|
Service Code
|
MSDRG 639
|
| Min. Negotiated Rate |
$14,813.75 |
| Max. Negotiated Rate |
$14,813.75 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,813.75
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS Q9963
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: AlohaCare Medicaid |
$31.00
|
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicaid |
$84.00
|
| Rate for Payer: AlohaCare Medicare |
$22.63
|
| Rate for Payer: AlohaCare Medicare |
$19.22
|
| Rate for Payer: AlohaCare Medicare |
$52.08
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Devoted Health Medicare |
$21.08
|
| Rate for Payer: Devoted Health Medicare |
$24.82
|
| Rate for Payer: Devoted Health Medicare |
$57.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$159.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Humana Medicare |
$19.22
|
| Rate for Payer: Humana Medicare |
$52.08
|
| Rate for Payer: Humana Medicare |
$22.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.08
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.63
|
| Rate for Payer: University Health Alliance Commercial |
$122.46
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
|
|
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS Q9963
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Health Management Network Commercial |
$142.80
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: MDX Hawaii PPO |
$162.96
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00378047701
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079028620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00378047701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51079028601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079028620
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
DIAZEPAM 10 MG TABLET [2403]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51079028601
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
DIAZEPAM 2 MG TABLET [2404]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 51079028420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
DIAZEPAM 2 MG TABLET [2404]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 51079028420
|
|
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
|
|
