|
DENTAL AND ORAL DISEASES WITHOUT CC/MCC
|
Facility
|
IP
|
$21,442.14
|
|
|
Service Code
|
MSDRG 159
|
| Min. Negotiated Rate |
$21,442.14 |
| Max. Negotiated Rate |
$21,442.14 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21,442.14
|
|
|
DEPRESSIVE NEUROSES
|
Facility
|
IP
|
$10,759.31
|
|
|
Service Code
|
MSDRG 881
|
| Min. Negotiated Rate |
$10,759.31 |
| Max. Negotiated Rate |
$10,759.31 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,759.31
|
|
|
DERMABOND ADVANCED PEN DNX12
|
Facility
|
OP
|
$127.00
|
|
| Hospital Charge Code |
12912337
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.50 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: AlohaCare Medicaid |
$63.50
|
| Rate for Payer: AlohaCare Medicare |
$63.50
|
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Devoted Health Medicare |
$69.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.65
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Humana Medicare |
$63.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.50
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.50
|
| Rate for Payer: University Health Alliance Commercial |
$92.57
|
|
|
DERMABOND ADVANCED PEN DNX12
|
Facility
|
IP
|
$127.00
|
|
| Hospital Charge Code |
12912337
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$82.55
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$114.30
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
desmopressin 4 mcg/1ml ampule [HHSC]
|
Facility
|
OP
|
$177.40
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
2500219
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$172.08 |
| Rate for Payer: AlohaCare Medicaid |
$88.70
|
| Rate for Payer: AlohaCare Medicaid |
$172.97
|
| Rate for Payer: AlohaCare Medicare |
$172.97
|
| Rate for Payer: AlohaCare Medicare |
$88.70
|
| Rate for Payer: Cash Price |
$115.31
|
| Rate for Payer: Cash Price |
$115.31
|
| Rate for Payer: Cash Price |
$224.87
|
| Rate for Payer: Cash Price |
$224.87
|
| Rate for Payer: Devoted Health Medicare |
$97.57
|
| Rate for Payer: Devoted Health Medicare |
$190.27
|
| 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 |
$172.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.70
|
| 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 |
$168.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$328.65
|
| Rate for Payer: Health Management Network Commercial |
$294.06
|
| Rate for Payer: Health Management Network Commercial |
$150.79
|
| Rate for Payer: Humana Medicare |
$172.97
|
| Rate for Payer: Humana Medicare |
$88.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$176.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$90.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$88.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$172.97
|
| Rate for Payer: MDX Hawaii PPO |
$172.08
|
| Rate for Payer: MDX Hawaii PPO |
$335.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$172.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$106.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.97
|
| Rate for Payer: University Health Alliance Commercial |
$129.31
|
| Rate for Payer: University Health Alliance Commercial |
$252.16
|
|
|
desmopressin 4 mcg/1ml ampule [HHSC]
|
Facility
|
IP
|
$177.40
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
2500219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$150.79 |
| Max. Negotiated Rate |
$172.08 |
| Rate for Payer: Cash Price |
$115.31
|
| Rate for Payer: Cash Price |
$224.87
|
| Rate for Payer: Health Management Network Commercial |
$150.79
|
| Rate for Payer: Health Management Network Commercial |
$294.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.36
|
| Rate for Payer: MDX Hawaii PPO |
$335.57
|
| Rate for Payer: MDX Hawaii PPO |
$172.08
|
|
|
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 17110
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$33.45 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$256.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.45
|
|
|
DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION
|
Facility
|
OP
|
$5,655.00
|
|
|
Service Code
|
CPT 46922
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$5,655.00 |
| Rate for Payer: AlohaCare Medicaid |
$672.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,655.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$700.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
|
|
DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION
|
Facility
|
OP
|
$4,035.20
|
|
|
Service Code
|
CPT 54060
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$672.48
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,634.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
dexamethasone 10 mg/1ml vial [HHSC]
|
Facility
|
OP
|
$8.67
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500220
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$8.41 |
| Rate for Payer: AlohaCare Medicaid |
$4.33
|
| Rate for Payer: AlohaCare Medicare |
$4.33
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Devoted Health Medicare |
$4.77
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.33
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.24
|
| Rate for Payer: Health Management Network Commercial |
$7.37
|
| Rate for Payer: Humana Medicare |
$4.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.33
|
| Rate for Payer: MDX Hawaii PPO |
$8.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.33
|
| Rate for Payer: University Health Alliance Commercial |
$6.32
|
|
|
dexamethasone 10 mg/1ml vial [HHSC]
|
Facility
|
IP
|
$8.67
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.37 |
| Max. Negotiated Rate |
$8.41 |
| Rate for Payer: Cash Price |
$5.64
|
| Rate for Payer: Health Management Network Commercial |
$7.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.80
|
| Rate for Payer: MDX Hawaii PPO |
$8.41
|
|
|
dexamethasone 10 mg/mL (PF) vial [HHSC]
|
Facility
|
OP
|
$40.30
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2501060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$39.09 |
| Rate for Payer: AlohaCare Medicaid |
$20.15
|
| Rate for Payer: AlohaCare Medicare |
$20.15
|
| Rate for Payer: Cash Price |
$26.20
|
| Rate for Payer: Cash Price |
$26.20
|
| Rate for Payer: Devoted Health Medicare |
$22.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.15
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.28
|
| Rate for Payer: Health Management Network Commercial |
$34.26
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.15
|
| Rate for Payer: MDX Hawaii PPO |
$39.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.15
|
| Rate for Payer: University Health Alliance Commercial |
$29.37
|
|
|
dexamethasone 10 mg/mL (PF) vial [HHSC]
|
Facility
|
IP
|
$40.30
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2501060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.26 |
| Max. Negotiated Rate |
$39.09 |
| Rate for Payer: Cash Price |
$26.20
|
| Rate for Payer: Health Management Network Commercial |
$34.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.27
|
| Rate for Payer: MDX Hawaii PPO |
$39.09
|
|
|
dexamethasone 4 mg/ml vial [HHSC]
|
Facility
|
IP
|
$5.18
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500222
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$5.02 |
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Health Management Network Commercial |
$12.48
|
| Rate for Payer: Health Management Network Commercial |
$4.40
|
| Rate for Payer: Health Management Network Commercial |
$4.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.21
|
| Rate for Payer: MDX Hawaii PPO |
$4.84
|
| Rate for Payer: MDX Hawaii PPO |
$14.24
|
| Rate for Payer: MDX Hawaii PPO |
$5.02
|
|
|
dexamethasone 4 mg/ml vial [HHSC]
|
Facility
|
OP
|
$14.68
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2500222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$14.24 |
| Rate for Payer: Kaiser Permanente Commercial |
$4.49
|
| Rate for Payer: AlohaCare Medicaid |
$7.34
|
| Rate for Payer: AlohaCare Medicaid |
$2.59
|
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$7.34
|
| Rate for Payer: AlohaCare Medicare |
$2.59
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Cash Price |
$9.54
|
| Rate for Payer: Cash Price |
$3.37
|
| Rate for Payer: Devoted Health Medicare |
$8.07
|
| Rate for Payer: Devoted Health Medicare |
$2.85
|
| Rate for Payer: Devoted Health Medicare |
$2.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.92
|
| Rate for Payer: Health Management Network Commercial |
$4.40
|
| Rate for Payer: Health Management Network Commercial |
$12.48
|
| Rate for Payer: Health Management Network Commercial |
$4.24
|
| Rate for Payer: Humana Medicare |
$7.34
|
| Rate for Payer: Humana Medicare |
$2.50
|
| Rate for Payer: Humana Medicare |
$2.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.59
|
| Rate for Payer: MDX Hawaii PPO |
$5.02
|
| Rate for Payer: MDX Hawaii PPO |
$4.84
|
| Rate for Payer: MDX Hawaii PPO |
$14.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.59
|
| Rate for Payer: University Health Alliance Commercial |
$10.70
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$3.78
|
|
|
dexamethasone 4 mg tablet [HHSC]
|
Facility
|
IP
|
$6.70
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
2500221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Cash Price |
$4.36
|
| Rate for Payer: Health Management Network Commercial |
$5.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.03
|
| Rate for Payer: MDX Hawaii PPO |
$6.50
|
|
|
dexamethasone 4 mg tablet [HHSC]
|
Facility
|
OP
|
$6.70
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
2500221
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: AlohaCare Medicaid |
$3.35
|
| Rate for Payer: AlohaCare Medicare |
$3.35
|
| Rate for Payer: Cash Price |
$4.36
|
| Rate for Payer: Cash Price |
$4.36
|
| Rate for Payer: Devoted Health Medicare |
$3.69
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.35
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.37
|
| Rate for Payer: Health Management Network Commercial |
$5.70
|
| Rate for Payer: Humana Medicare |
$3.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.35
|
| Rate for Payer: MDX Hawaii PPO |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.35
|
| Rate for Payer: University Health Alliance Commercial |
$4.88
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
OP
|
$40.36
|
|
|
Service Code
|
NDC 66794023042
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.18 |
| Max. Negotiated Rate |
$39.15 |
| Rate for Payer: AlohaCare Medicaid |
$20.18
|
| Rate for Payer: AlohaCare Medicare |
$20.18
|
| Rate for Payer: Cash Price |
$26.23
|
| Rate for Payer: Devoted Health Medicare |
$22.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.34
|
| Rate for Payer: Health Management Network Commercial |
$34.31
|
| Rate for Payer: Humana Medicare |
$20.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.18
|
| Rate for Payer: MDX Hawaii PPO |
$39.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.18
|
| Rate for Payer: University Health Alliance Commercial |
$29.42
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
IP
|
$44.74
|
|
|
Service Code
|
NDC 00409163802
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.03 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
OP
|
$113.91
|
|
|
Service Code
|
NDC 16729043293
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$110.49 |
| Rate for Payer: AlohaCare Medicaid |
$56.95
|
| Rate for Payer: AlohaCare Medicare |
$56.95
|
| Rate for Payer: Cash Price |
$74.04
|
| Rate for Payer: Devoted Health Medicare |
$62.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.21
|
| Rate for Payer: Health Management Network Commercial |
$96.82
|
| Rate for Payer: Humana Medicare |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.95
|
| Rate for Payer: MDX Hawaii PPO |
$110.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.95
|
| Rate for Payer: University Health Alliance Commercial |
$83.03
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
IP
|
$113.91
|
|
|
Service Code
|
NDC 16729043293
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.82 |
| Max. Negotiated Rate |
$110.49 |
| Rate for Payer: Cash Price |
$74.04
|
| Rate for Payer: Health Management Network Commercial |
$96.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.52
|
| Rate for Payer: MDX Hawaii PPO |
$110.49
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
OP
|
$44.74
|
|
|
Service Code
|
NDC 00409163802
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
IP
|
$41.35
|
|
|
Service Code
|
NDC 70860060503
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.15 |
| Max. Negotiated Rate |
$40.11 |
| Rate for Payer: Cash Price |
$26.88
|
| Rate for Payer: Health Management Network Commercial |
$35.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.22
|
| Rate for Payer: MDX Hawaii PPO |
$40.11
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
IP
|
$40.36
|
|
|
Service Code
|
NDC 66794023042
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.31 |
| Max. Negotiated Rate |
$39.15 |
| Rate for Payer: Cash Price |
$26.23
|
| Rate for Payer: Health Management Network Commercial |
$34.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.32
|
| Rate for Payer: MDX Hawaii PPO |
$39.15
|
|
|
dexmedeTOMIDine 200 mcg/2mL vial [HHSC]
|
Facility
|
OP
|
$113.91
|
|
|
Service Code
|
NDC 16729023993
|
| Hospital Charge Code |
2500226
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$110.49 |
| Rate for Payer: AlohaCare Medicaid |
$56.95
|
| Rate for Payer: AlohaCare Medicare |
$56.95
|
| Rate for Payer: Cash Price |
$74.04
|
| Rate for Payer: Devoted Health Medicare |
$62.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.21
|
| Rate for Payer: Health Management Network Commercial |
$96.82
|
| Rate for Payer: Humana Medicare |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.95
|
| Rate for Payer: MDX Hawaii PPO |
$110.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$68.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.95
|
| Rate for Payer: University Health Alliance Commercial |
$83.03
|
|
