|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 70860030142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
NDC 00641601410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00641601310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
NDC 00641601501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION [97252]
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
NDC 00641601510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Health Management Network Commercial |
$33.15
|
| Rate for Payer: MDX Hawaii PPO |
$37.83
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00093031901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687072801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687072811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68682000710
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00093031901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68682000710
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687072811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DILTIAZEM 60 MG TABLET [2476]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687072801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687019511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687019501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687019511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR [29270]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687019501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 24979002707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687020601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
NDC 00187079642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.53 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.85
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.53
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: University Health Alliance Commercial |
$75.08
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687020601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687020611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
NDC 00187079642
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.55 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 24979002707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR [29272]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687020611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
