|
hydrocortisone 25 mg suppository [HHSC]
|
Facility
|
OP
|
$91.95
|
|
|
Service Code
|
NDC 00574709012
|
| Hospital Charge Code |
2500394
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.98 |
| Max. Negotiated Rate |
$89.19 |
| Rate for Payer: AlohaCare Medicaid |
$45.98
|
| Rate for Payer: AlohaCare Medicare |
$45.98
|
| Rate for Payer: Cash Price |
$59.77
|
| Rate for Payer: Devoted Health Medicare |
$50.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.35
|
| Rate for Payer: Health Management Network Commercial |
$78.16
|
| Rate for Payer: Humana Medicare |
$45.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.98
|
| Rate for Payer: MDX Hawaii PPO |
$89.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.98
|
| Rate for Payer: University Health Alliance Commercial |
$67.02
|
|
|
hydrocortisone sod succ 100mg/2ml AOV [HHSC]
|
Facility
|
OP
|
$125.58
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
2500391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.20 |
| Max. Negotiated Rate |
$121.81 |
| Rate for Payer: AlohaCare Medicaid |
$62.79
|
| Rate for Payer: AlohaCare Medicaid |
$34.97
|
| Rate for Payer: AlohaCare Medicare |
$34.97
|
| Rate for Payer: AlohaCare Medicare |
$62.79
|
| Rate for Payer: Cash Price |
$45.46
|
| Rate for Payer: Cash Price |
$81.63
|
| Rate for Payer: Cash Price |
$81.63
|
| Rate for Payer: Cash Price |
$45.46
|
| Rate for Payer: Devoted Health Medicare |
$69.07
|
| Rate for Payer: Devoted Health Medicare |
$38.47
|
| 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 |
$34.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$62.79
|
| 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 |
$119.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.44
|
| Rate for Payer: Health Management Network Commercial |
$59.45
|
| Rate for Payer: Health Management Network Commercial |
$106.74
|
| Rate for Payer: Humana Medicare |
$62.79
|
| Rate for Payer: Humana Medicare |
$34.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$62.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.97
|
| Rate for Payer: MDX Hawaii PPO |
$121.81
|
| Rate for Payer: MDX Hawaii PPO |
$67.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$62.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$62.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$41.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$62.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.97
|
| Rate for Payer: University Health Alliance Commercial |
$91.54
|
| Rate for Payer: University Health Alliance Commercial |
$50.98
|
|
|
hydrocortisone sod succ 100mg/2ml AOV [HHSC]
|
Facility
|
IP
|
$125.58
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
2500391
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.74 |
| Max. Negotiated Rate |
$121.81 |
| Rate for Payer: Cash Price |
$81.63
|
| Rate for Payer: Cash Price |
$45.46
|
| Rate for Payer: Health Management Network Commercial |
$106.74
|
| Rate for Payer: Health Management Network Commercial |
$59.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.95
|
| Rate for Payer: MDX Hawaii PPO |
$67.84
|
| Rate for Payer: MDX Hawaii PPO |
$121.81
|
|
|
hydrogen peroxide 3% 237 mL [HHSC]
|
Facility
|
OP
|
$32.89
|
|
|
Service Code
|
NDC 00869470410
|
| Hospital Charge Code |
2500886
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.45 |
| Max. Negotiated Rate |
$31.90 |
| Rate for Payer: AlohaCare Medicaid |
$16.45
|
| Rate for Payer: AlohaCare Medicare |
$16.45
|
| Rate for Payer: Cash Price |
$21.38
|
| Rate for Payer: Devoted Health Medicare |
$18.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.25
|
| Rate for Payer: Health Management Network Commercial |
$27.96
|
| Rate for Payer: Humana Medicare |
$16.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.45
|
| Rate for Payer: MDX Hawaii PPO |
$31.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.45
|
| Rate for Payer: University Health Alliance Commercial |
$23.97
|
|
|
hydrogen peroxide 3% 237 mL [HHSC]
|
Facility
|
IP
|
$32.89
|
|
|
Service Code
|
NDC 00869470410
|
| Hospital Charge Code |
2500886
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$31.90 |
| Rate for Payer: Cash Price |
$21.38
|
| Rate for Payer: Health Management Network Commercial |
$27.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.60
|
| Rate for Payer: MDX Hawaii PPO |
$31.90
|
|
|
hydrogen peroxide 3% 237 mL [HHSC]
|
Facility
|
OP
|
$8.62
|
|
|
Service Code
|
NDC 00869087134
|
| Hospital Charge Code |
2500886
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.31 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: AlohaCare Medicaid |
$4.31
|
| Rate for Payer: AlohaCare Medicare |
$4.31
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Devoted Health Medicare |
$4.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.19
|
| Rate for Payer: Health Management Network Commercial |
$7.33
|
| Rate for Payer: Humana Medicare |
$4.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.31
|
| Rate for Payer: MDX Hawaii PPO |
$8.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.31
|
| Rate for Payer: University Health Alliance Commercial |
$6.28
|
|
|
hydrogen peroxide 3% 237 mL [HHSC]
|
Facility
|
IP
|
$8.62
|
|
|
Service Code
|
NDC 00869087134
|
| Hospital Charge Code |
2500886
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.33 |
| Max. Negotiated Rate |
$8.36 |
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: Health Management Network Commercial |
$7.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$8.36
|
|
|
hydrogen peroxide 3% 473 mL [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00869087143
|
| Hospital Charge Code |
2500397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
hydrogen peroxide 3% 473 mL [HHSC]
|
Facility
|
IP
|
$49.27
|
|
|
Service Code
|
NDC 00869470610
|
| Hospital Charge Code |
2500397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.88 |
| Max. Negotiated Rate |
$47.79 |
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Health Management Network Commercial |
$41.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.34
|
| Rate for Payer: MDX Hawaii PPO |
$47.79
|
|
|
hydrogen peroxide 3% 473 mL [HHSC]
|
Facility
|
OP
|
$49.27
|
|
|
Service Code
|
NDC 00869470610
|
| Hospital Charge Code |
2500397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$47.79 |
| Rate for Payer: AlohaCare Medicaid |
$24.64
|
| Rate for Payer: AlohaCare Medicare |
$24.64
|
| Rate for Payer: Cash Price |
$32.03
|
| Rate for Payer: Devoted Health Medicare |
$27.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.81
|
| Rate for Payer: Health Management Network Commercial |
$41.88
|
| Rate for Payer: Humana Medicare |
$24.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.64
|
| Rate for Payer: MDX Hawaii PPO |
$47.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.64
|
| Rate for Payer: University Health Alliance Commercial |
$35.91
|
|
|
hydrogen peroxide 3% 473 mL [HHSC]
|
Facility
|
IP
|
$11.07
|
|
|
Service Code
|
NDC 46122077334
|
| Hospital Charge Code |
2500397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$10.74 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$9.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.96
|
| Rate for Payer: MDX Hawaii PPO |
$10.74
|
|
|
hydrogen peroxide 3% 473 mL [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00869087143
|
| Hospital Charge Code |
2500397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
hydrogen peroxide 3% 473 mL [HHSC]
|
Facility
|
OP
|
$11.07
|
|
|
Service Code
|
NDC 46122077334
|
| Hospital Charge Code |
2500397
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.54 |
| Max. Negotiated Rate |
$10.74 |
| Rate for Payer: AlohaCare Medicaid |
$5.54
|
| Rate for Payer: AlohaCare Medicare |
$5.54
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$6.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.52
|
| Rate for Payer: Health Management Network Commercial |
$9.41
|
| Rate for Payer: Humana Medicare |
$5.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.54
|
| Rate for Payer: MDX Hawaii PPO |
$10.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.54
|
| Rate for Payer: University Health Alliance Commercial |
$8.07
|
|
|
HYDROmorphone 10 mg/1ml (PF) vial [HHSC]
|
Facility
|
OP
|
$23.29
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
2500400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: AlohaCare Medicaid |
$11.64
|
| Rate for Payer: AlohaCare Medicaid |
$12.01
|
| Rate for Payer: AlohaCare Medicare |
$12.01
|
| Rate for Payer: AlohaCare Medicare |
$11.64
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cash Price |
$15.14
|
| Rate for Payer: Cash Price |
$15.14
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Devoted Health Medicare |
$12.81
|
| Rate for Payer: Devoted Health Medicare |
$13.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.82
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Health Management Network Commercial |
$19.80
|
| Rate for Payer: Humana Medicare |
$11.64
|
| Rate for Payer: Humana Medicare |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.01
|
| Rate for Payer: MDX Hawaii PPO |
$22.59
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.01
|
| Rate for Payer: University Health Alliance Commercial |
$16.98
|
| Rate for Payer: University Health Alliance Commercial |
$17.51
|
|
|
HYDROmorphone 10 mg/1ml (PF) vial [HHSC]
|
Facility
|
IP
|
$23.29
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
2500400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$22.59 |
| Rate for Payer: Cash Price |
$15.14
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Health Management Network Commercial |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
| Rate for Payer: MDX Hawaii PPO |
$22.59
|
|
|
HYDROmorphone 1 mg/1ml (PF) injection [HHSC]
|
Facility
|
OP
|
$17.08
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
2500399
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: AlohaCare Medicaid |
$8.54
|
| Rate for Payer: AlohaCare Medicaid |
$10.41
|
| Rate for Payer: AlohaCare Medicaid |
$5.37
|
| Rate for Payer: AlohaCare Medicare |
$10.41
|
| Rate for Payer: AlohaCare Medicare |
$5.37
|
| Rate for Payer: AlohaCare Medicare |
$8.54
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Devoted Health Medicare |
$11.45
|
| Rate for Payer: Devoted Health Medicare |
$9.39
|
| Rate for Payer: Devoted Health Medicare |
$5.91
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.23
|
| Rate for Payer: Health Management Network Commercial |
$9.13
|
| Rate for Payer: Health Management Network Commercial |
$14.52
|
| Rate for Payer: Health Management Network Commercial |
$17.70
|
| Rate for Payer: Humana Medicare |
$8.54
|
| Rate for Payer: Humana Medicare |
$5.37
|
| Rate for Payer: Humana Medicare |
$10.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.41
|
| Rate for Payer: MDX Hawaii PPO |
$20.20
|
| Rate for Payer: MDX Hawaii PPO |
$10.42
|
| Rate for Payer: MDX Hawaii PPO |
$16.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.54
|
| Rate for Payer: University Health Alliance Commercial |
$15.18
|
| Rate for Payer: University Health Alliance Commercial |
$12.45
|
| Rate for Payer: University Health Alliance Commercial |
$7.83
|
|
|
HYDROmorphone 1 mg/1ml (PF) injection [HHSC]
|
Facility
|
IP
|
$17.08
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
2500399
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.52 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Cash Price |
$11.10
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Health Management Network Commercial |
$17.70
|
| Rate for Payer: Health Management Network Commercial |
$9.13
|
| Rate for Payer: Health Management Network Commercial |
$14.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.37
|
| Rate for Payer: MDX Hawaii PPO |
$16.57
|
| Rate for Payer: MDX Hawaii PPO |
$10.42
|
| Rate for Payer: MDX Hawaii PPO |
$20.20
|
|
|
HYDROmorphone 2 mg/1ml (PF) injection [HHSC]
|
Facility
|
OP
|
$22.42
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
2500402
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$21.75 |
| Rate for Payer: AlohaCare Medicaid |
$11.21
|
| Rate for Payer: AlohaCare Medicaid |
$10.01
|
| Rate for Payer: AlohaCare Medicaid |
$11.23
|
| Rate for Payer: AlohaCare Medicaid |
$12.01
|
| Rate for Payer: AlohaCare Medicaid |
$5.36
|
| Rate for Payer: AlohaCare Medicare |
$11.21
|
| Rate for Payer: AlohaCare Medicare |
$11.23
|
| Rate for Payer: AlohaCare Medicare |
$12.01
|
| Rate for Payer: AlohaCare Medicare |
$5.36
|
| Rate for Payer: AlohaCare Medicare |
$10.01
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Cash Price |
$14.60
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cash Price |
$14.60
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Devoted Health Medicare |
$12.33
|
| Rate for Payer: Devoted Health Medicare |
$5.89
|
| Rate for Payer: Devoted Health Medicare |
$12.35
|
| Rate for Payer: Devoted Health Medicare |
$13.21
|
| Rate for Payer: Devoted Health Medicare |
$11.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.82
|
| Rate for Payer: Health Management Network Commercial |
$19.06
|
| Rate for Payer: Health Management Network Commercial |
$17.02
|
| Rate for Payer: Health Management Network Commercial |
$9.10
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Health Management Network Commercial |
$19.09
|
| Rate for Payer: Humana Medicare |
$11.21
|
| Rate for Payer: Humana Medicare |
$5.36
|
| Rate for Payer: Humana Medicare |
$10.01
|
| Rate for Payer: Humana Medicare |
$11.23
|
| Rate for Payer: Humana Medicare |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.01
|
| Rate for Payer: MDX Hawaii PPO |
$21.75
|
| Rate for Payer: MDX Hawaii PPO |
$21.79
|
| Rate for Payer: MDX Hawaii PPO |
$19.42
|
| Rate for Payer: MDX Hawaii PPO |
$10.39
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.21
|
| Rate for Payer: University Health Alliance Commercial |
$7.81
|
| Rate for Payer: University Health Alliance Commercial |
$16.34
|
| Rate for Payer: University Health Alliance Commercial |
$16.37
|
| Rate for Payer: University Health Alliance Commercial |
$14.59
|
| Rate for Payer: University Health Alliance Commercial |
$17.51
|
|
|
HYDROmorphone 2 mg/1ml (PF) injection [HHSC]
|
Facility
|
IP
|
$22.46
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
2500402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$21.79 |
| Rate for Payer: Cash Price |
$14.60
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Cash Price |
$14.57
|
| Rate for Payer: Cash Price |
$6.96
|
| Rate for Payer: Health Management Network Commercial |
$19.06
|
| Rate for Payer: Health Management Network Commercial |
$19.09
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Health Management Network Commercial |
$17.02
|
| Rate for Payer: Health Management Network Commercial |
$9.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: MDX Hawaii PPO |
$21.79
|
| Rate for Payer: MDX Hawaii PPO |
$19.42
|
| Rate for Payer: MDX Hawaii PPO |
$10.39
|
| Rate for Payer: MDX Hawaii PPO |
$21.75
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
|
|
HYDROmorphone 2 mg tablet [HHSC]
|
Facility
|
OP
|
$3.96
|
|
|
Service Code
|
NDC 60687057901
|
| Hospital Charge Code |
2500401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: AlohaCare Medicaid |
$1.98
|
| Rate for Payer: AlohaCare Medicare |
$1.98
|
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Devoted Health Medicare |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.76
|
| Rate for Payer: Health Management Network Commercial |
$3.37
|
| Rate for Payer: Humana Medicare |
$1.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.98
|
| Rate for Payer: MDX Hawaii PPO |
$3.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.98
|
| Rate for Payer: University Health Alliance Commercial |
$2.89
|
|
|
HYDROmorphone 2 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084042301
|
| Hospital Charge Code |
2500401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HYDROmorphone 2 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 42858030125
|
| Hospital Charge Code |
2500401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HYDROmorphone 2 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00406324301
|
| Hospital Charge Code |
2500401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
HYDROmorphone 2 mg tablet [HHSC]
|
Facility
|
IP
|
$3.96
|
|
|
Service Code
|
NDC 60687057901
|
| Hospital Charge Code |
2500401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.37 |
| Max. Negotiated Rate |
$3.84 |
| Rate for Payer: Cash Price |
$2.57
|
| Rate for Payer: Health Management Network Commercial |
$3.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.56
|
| Rate for Payer: MDX Hawaii PPO |
$3.84
|
|
|
HYDROmorphone 2 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 42858030125
|
| Hospital Charge Code |
2500401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
