|
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: Kaiser Permanente Commercial |
$5.40
|
| 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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| 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: Kaiser Permanente Commercial |
$3.60
|
| 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 60687019511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
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 |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| 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 |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
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: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
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 |
$31.93 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: AlohaCare Medicaid |
$51.50
|
| Rate for Payer: AlohaCare Medicare |
$31.93
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Devoted Health Medicare |
$35.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$97.85
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Humana Medicare |
$31.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.93
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.93
|
| 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: Kaiser Permanente Commercial |
$3.60
|
| 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 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: Kaiser Permanente Commercial |
$3.60
|
| 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: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
|
|
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 |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| 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 60687020611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$1.24
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$1.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$1.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.24
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
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 |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| 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 60687021711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
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 |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| 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 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: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
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: Kaiser Permanente Commercial |
$9.00
|
| 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 |
$2.17 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
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 |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
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: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
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: Kaiser Permanente Commercial |
$891.90
|
| Rate for Payer: MDX Hawaii PPO |
$961.27
|
|
