|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [4034]
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
NDC 69918073501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$357.00 |
| Max. Negotiated Rate |
$407.40 |
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Health Management Network Commercial |
$357.00
|
| Rate for Payer: MDX Hawaii PPO |
$407.40
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 68084008211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 68084008201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 68084008211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
ISOSORBIDE DINITRATE 10 MG TABLET [4064]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 68084008201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET [4065]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904662061
|
|
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
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET [4065]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 68001037500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET [4065]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 68001037500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET [4065]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904662061
|
|
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
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET [4065]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 68084008301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
ISOSORBIDE DINITRATE 20 MG TABLET [4065]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 68084008301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
ISOSORBIDE DINITRATE 5 MG TABLET [4068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00143176901
|
|
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
|
|
|
ISOSORBIDE DINITRATE 5 MG TABLET [4068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50268044711
|
|
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
|
|
|
ISOSORBIDE DINITRATE 5 MG TABLET [4068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00143176901
|
|
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
|
|
|
ISOSORBIDE DINITRATE 5 MG TABLET [4068]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68001037300
|
|
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
|
|
|
ISOSORBIDE DINITRATE 5 MG TABLET [4068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68001037300
|
|
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
|
|
|
ISOSORBIDE DINITRATE 5 MG TABLET [4068]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50268044711
|
|
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
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687078311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687078301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687078311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR [24521]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687078301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00904645061
|
|
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
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687079401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687079411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR [24268]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687079411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
