|
DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687021711
|
|
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 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687021701
|
|
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 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687021701
|
|
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 CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR [29274]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687021711
|
|
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 CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 60687022811
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 60687022801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 60687022811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 24979002907
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 24979002907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR [29276]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 60687022801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
OP
|
$991.00
|
|
|
Service Code
|
NDC 55566280001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$505.41 |
| Max. Negotiated Rate |
$961.27 |
| Rate for Payer: Cash Price |
$594.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$941.45
|
| Rate for Payer: Health Management Network Commercial |
$842.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$624.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$505.41
|
| Rate for Payer: MDX Hawaii PPO |
$961.27
|
| Rate for Payer: University Health Alliance Commercial |
$722.34
|
|
|
DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE [27467]
|
Facility
|
IP
|
$991.00
|
|
|
Service Code
|
NDC 55566280001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$842.35 |
| Max. Negotiated Rate |
$961.27 |
| Rate for Payer: Cash Price |
$594.60
|
| Rate for Payer: Health Management Network Commercial |
$842.35
|
| Rate for Payer: MDX Hawaii PPO |
$961.27
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 00121048905
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 00121048900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 00121048900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR [2511]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 00121048905
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 00904698520
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00904698520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 69339015119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69339015105
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 69339015119
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID [12556]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 69339015105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE [2509]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q0163
|
|
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
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE [2509]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS Q0163
|
|
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
|
|
|
DIPHENHYDRAMINE 50 MG CAPSULE [2510]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS Q0163
|
|
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
|
|
