|
HYDROCHLOROTHIAZIDE 25 MG TABLET [3720]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687059311
|
|
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
|
|
|
HYDROCHLOROTHIAZIDE 25 MG TABLET [3720]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687059311
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00406012562
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406012501
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687041811
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00406012562
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406012501
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00406012523
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687041811
|
|
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
|
|
|
HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET [28384]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00406012523
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406012323
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00406012362
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084089501
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084089501
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687039601
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687039611
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406012323
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687039601
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687039611
|
|
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
|
|
|
HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET [34505]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00406012362
|
|
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
|
|
|
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION [37848]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 60687041750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION [37848]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687041750
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION [37848]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687041744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION [37848]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 60687041744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION [37848]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 60687041771
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
