|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 63739005274
|
|
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: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 63739005274
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
NDC 16571012848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$13.02
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$13.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.02
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.02
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 00126027216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicare |
$9.92
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$10.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Humana Medicare |
$9.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.92
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.92
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH [9516]
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
NDC 00116200116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.07 |
| Max. Negotiated Rate |
$482.09 |
| Rate for Payer: AlohaCare Medicaid |
$248.50
|
| Rate for Payer: AlohaCare Medicare |
$154.07
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Devoted Health Medicare |
$168.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$154.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$472.15
|
| Rate for Payer: Health Management Network Commercial |
$422.45
|
| Rate for Payer: Humana Medicare |
$154.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$447.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$253.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$154.07
|
| Rate for Payer: MDX Hawaii PPO |
$482.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$154.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$154.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$154.07
|
| Rate for Payer: University Health Alliance Commercial |
$362.26
|
|
|
CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
NDC 67618020030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 67618020004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.80 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
|
|
CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
NDC 67618020030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$22.63
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$24.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$22.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.63
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.63
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
|
|
CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 67618020004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$27.16 |
| Rate for Payer: AlohaCare Medicaid |
$14.00
|
| Rate for Payer: AlohaCare Medicare |
$8.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Devoted Health Medicare |
$9.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.60
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Humana Medicare |
$8.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.68
|
| Rate for Payer: MDX Hawaii PPO |
$27.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.68
|
| Rate for Payer: University Health Alliance Commercial |
$20.41
|
|
|
CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
NDC 16571011148
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.00 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
|
|
CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID [109392]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
NDC 16571011148
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$38.80 |
| Rate for Payer: AlohaCare Medicaid |
$20.00
|
| Rate for Payer: AlohaCare Medicare |
$12.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Devoted Health Medicare |
$13.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.00
|
| Rate for Payer: Health Management Network Commercial |
$34.00
|
| Rate for Payer: Humana Medicare |
$12.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.40
|
| Rate for Payer: MDX Hawaii PPO |
$38.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.40
|
| Rate for Payer: University Health Alliance Commercial |
$29.16
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [134068]
|
Facility
|
OP
|
$95.00
|
|
|
Service Code
|
HCPCS J2401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: AlohaCare Medicaid |
$47.50
|
| Rate for Payer: AlohaCare Medicare |
$29.45
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Devoted Health Medicare |
$32.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.25
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Humana Medicare |
$29.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.45
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.45
|
| Rate for Payer: University Health Alliance Commercial |
$69.25
|
|
|
CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION [134068]
|
Facility
|
IP
|
$95.00
|
|
|
Service Code
|
HCPCS J2401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.75 |
| Max. Negotiated Rate |
$92.15 |
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$80.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.50
|
| Rate for Payer: MDX Hawaii PPO |
$92.15
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS J1205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
|
|
CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION [9526]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS J1205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.38 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: AlohaCare Medicaid |
$72.00
|
| Rate for Payer: AlohaCare Medicare |
$44.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Devoted Health Medicare |
$48.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$40.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$40.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Humana Medicare |
$44.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.64
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$86.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.64
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS J3230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
|
|
CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION [1649]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS J3230
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.07 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: AlohaCare Medicaid |
$50.00
|
| Rate for Payer: AlohaCare Medicare |
$31.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Devoted Health Medicare |
$34.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$27.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$95.00
|
| Rate for Payer: Health Management Network Commercial |
$85.00
|
| Rate for Payer: Humana Medicare |
$31.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$90.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.00
|
| Rate for Payer: MDX Hawaii PPO |
$97.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$60.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.00
|
| Rate for Payer: University Health Alliance Commercial |
$72.89
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 68462086201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 69238105601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicare |
$7.13
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Devoted Health Medicare |
$7.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Humana Medicare |
$7.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.13
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.13
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
NDC 69238105601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
|
|
CHLORPROMAZINE 25 MG TABLET [1656]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
NDC 68462086201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: AlohaCare Medicaid |
$11.50
|
| Rate for Payer: AlohaCare Medicare |
$7.13
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Devoted Health Medicare |
$7.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Humana Medicare |
$7.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.13
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.13
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 51079005820
|
|
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: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687031725
|
|
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: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687031795
|
|
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: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
CHLORTHALIDONE 25 MG TABLET [1661]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 51079005820
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
