|
ZOLMITRIPTAN 2.5 MG DISINTEGRATING TABLET [29868]
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
NDC 68382071586
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.95 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
|
|
ZOLMITRIPTAN 2.5 MG DISINTEGRATING TABLET [29868]
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
NDC 68382071569
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.77 |
| Max. Negotiated Rate |
$123.19 |
| Rate for Payer: Cash Price |
$76.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.65
|
| Rate for Payer: Health Management Network Commercial |
$107.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.77
|
| Rate for Payer: MDX Hawaii PPO |
$123.19
|
| Rate for Payer: University Health Alliance Commercial |
$92.57
|
|
|
ZOLMITRIPTAN 2.5 MG TABLET [21588]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
NDC 68001024901
|
|
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: MDX Hawaii PPO |
$122.22
|
|
|
ZOLMITRIPTAN 2.5 MG TABLET [21588]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
NDC 68001024901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.26 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
ZOLPIDEM 5 MG TABLET [11701]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904608261
|
|
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: MDX Hawaii PPO |
$0.97
|
|
|
ZOLPIDEM 5 MG TABLET [11701]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904608261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
ZONISAMIDE 100 MG CAPSULE [27780]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 68001024400
|
|
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: MDX Hawaii PPO |
$7.76
|
|
|
ZONISAMIDE 100 MG CAPSULE [27780]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 68001024400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
