Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

dextrose 5% -water 100 ml [HHSC]

Facility

$8.53

Service Code	HCPCS J7060
Hospital Charge Code	2500230
Hospital Revenue Code	250
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$8.27
Rate for Payer: Cash Price	$5.54
Rate for Payer: Health Management Network Commercial	$7.25
Rate for Payer: Kaiser Permanente Commercial	$7.68
Rate for Payer: MDX Hawaii PPO	$8.27

dextrose 5%-water 250 mL [HHSC]

Facility

$13.01

Service Code	HCPCS J7060
Hospital Charge Code	2500232
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$12.62
Rate for Payer: AlohaCare Medicaid	$6.50
Rate for Payer: AlohaCare Medicare	$6.50
Rate for Payer: Cash Price	$8.46
Rate for Payer: Cash Price	$8.46
Rate for Payer: Devoted Health Medicare	$7.16
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Medicare	$6.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$12.36
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Humana Medicare	$6.50
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: Kaiser Permanente Medicaid	$6.64
Rate for Payer: Kaiser Permanente Medicare	$6.50
Rate for Payer: MDX Hawaii PPO	$12.62
Rate for Payer: Ohana Health Plan Medicaid	$6.50
Rate for Payer: Ohana Health Plan Medicare	$6.50
Rate for Payer: UnitedHealthcare Medicaid	$7.81
Rate for Payer: UnitedHealthcare Medicare	$6.50
Rate for Payer: University Health Alliance Commercial	$9.48

dextrose 5%-water 250 mL [HHSC]

Facility

$13.01

Service Code	HCPCS J7060
Hospital Charge Code	2500232
Hospital Revenue Code	250
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$12.62
Rate for Payer: Cash Price	$8.46
Rate for Payer: Health Management Network Commercial	$11.06
Rate for Payer: Kaiser Permanente Commercial	$11.71
Rate for Payer: MDX Hawaii PPO	$12.62

dextrose 5%-water 500 ml [HHSC]

Facility

$13.81

Service Code	HCPCS J7060
Hospital Charge Code	2500234
Hospital Revenue Code	250
Min. Negotiated Rate	$11.74
Max. Negotiated Rate	$13.40
Rate for Payer: Cash Price	$8.98
Rate for Payer: Cash Price	$15.25
Rate for Payer: Health Management Network Commercial	$11.74
Rate for Payer: Health Management Network Commercial	$19.94
Rate for Payer: Kaiser Permanente Commercial	$12.43
Rate for Payer: Kaiser Permanente Commercial	$21.11
Rate for Payer: MDX Hawaii PPO	$22.76
Rate for Payer: MDX Hawaii PPO	$13.40

dextrose 5%-water 500 ml [HHSC]

Facility

$13.81

Service Code	HCPCS J7060
Hospital Charge Code	2500234
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$13.40
Rate for Payer: AlohaCare Medicaid	$6.91
Rate for Payer: AlohaCare Medicaid	$11.73
Rate for Payer: AlohaCare Medicare	$11.73
Rate for Payer: AlohaCare Medicare	$6.91
Rate for Payer: Cash Price	$15.25
Rate for Payer: Cash Price	$8.98
Rate for Payer: Cash Price	$8.98
Rate for Payer: Cash Price	$15.25
Rate for Payer: Devoted Health Medicare	$7.60
Rate for Payer: Devoted Health Medicare	$12.90
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Medicare	$11.73
Rate for Payer: Hawaii Medical Service Association Medicare	$6.91
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$13.12
Rate for Payer: Hawaii Western Management Group Commercial	$22.29
Rate for Payer: Health Management Network Commercial	$19.94
Rate for Payer: Health Management Network Commercial	$11.74
Rate for Payer: Humana Medicare	$6.91
Rate for Payer: Humana Medicare	$11.73
Rate for Payer: Kaiser Permanente Commercial	$12.43
Rate for Payer: Kaiser Permanente Commercial	$21.11
Rate for Payer: Kaiser Permanente Medicaid	$11.96
Rate for Payer: Kaiser Permanente Medicaid	$7.04
Rate for Payer: Kaiser Permanente Medicare	$6.91
Rate for Payer: Kaiser Permanente Medicare	$11.73
Rate for Payer: MDX Hawaii PPO	$13.40
Rate for Payer: MDX Hawaii PPO	$22.76
Rate for Payer: Ohana Health Plan Medicaid	$11.73
Rate for Payer: Ohana Health Plan Medicaid	$6.91
Rate for Payer: Ohana Health Plan Medicare	$6.91
Rate for Payer: Ohana Health Plan Medicare	$11.73
Rate for Payer: UnitedHealthcare Medicaid	$14.08
Rate for Payer: UnitedHealthcare Medicaid	$8.29
Rate for Payer: UnitedHealthcare Medicare	$6.91
Rate for Payer: UnitedHealthcare Medicare	$11.73
Rate for Payer: University Health Alliance Commercial	$10.07
Rate for Payer: University Health Alliance Commercial	$17.10

dextrose 5%- water 50ml [HHSC]

Facility

$8.53

Service Code	HCPCS J7060
Hospital Charge Code	2500233
Hospital Revenue Code	636
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$8.27
Rate for Payer: AlohaCare Medicaid	$4.26
Rate for Payer: AlohaCare Medicare	$4.26
Rate for Payer: Cash Price	$5.54
Rate for Payer: Cash Price	$5.54
Rate for Payer: Devoted Health Medicare	$4.69
Rate for Payer: Hawaii Medical Service Association ABD	$2.03
Rate for Payer: Hawaii Medical Service Association Medicare	$4.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2.03
Rate for Payer: Hawaii Western Management Group Commercial	$8.10
Rate for Payer: Health Management Network Commercial	$7.25
Rate for Payer: Humana Medicare	$4.26
Rate for Payer: Kaiser Permanente Commercial	$7.68
Rate for Payer: Kaiser Permanente Medicaid	$4.35
Rate for Payer: Kaiser Permanente Medicare	$4.26
Rate for Payer: MDX Hawaii PPO	$8.27
Rate for Payer: Ohana Health Plan Medicaid	$4.26
Rate for Payer: Ohana Health Plan Medicare	$4.26
Rate for Payer: UnitedHealthcare Medicaid	$5.12
Rate for Payer: UnitedHealthcare Medicare	$4.26
Rate for Payer: University Health Alliance Commercial	$6.22

dextrose 5%- water 50ml [HHSC]

Facility

$8.53

Service Code	HCPCS J7060
Hospital Charge Code	2500233
Hospital Revenue Code	250
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$8.27
Rate for Payer: Cash Price	$5.54
Rate for Payer: Health Management Network Commercial	$7.25
Rate for Payer: Kaiser Permanente Commercial	$7.68
Rate for Payer: MDX Hawaii PPO	$8.27

DHEA Sulfate FSI

Facility

$146.00

Service Code	HCPCS 82627
Hospital Charge Code	8117901
Hospital Revenue Code	301
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$94.90
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: MDX Hawaii PPO	$141.62

DHEA Sulfate FSI

Facility

$146.00

Service Code	HCPCS 82627
Hospital Charge Code	8117901
Hospital Revenue Code	301
Min. Negotiated Rate	$22.23
Max. Negotiated Rate	$141.62
Rate for Payer: AlohaCare Medicaid	$73.00
Rate for Payer: AlohaCare Medicare	$73.00
Rate for Payer: Cash Price	$94.90
Rate for Payer: Cash Price	$94.90
Rate for Payer: Devoted Health Medicare	$80.30
Rate for Payer: Hawaii Medical Service Association ABD	$30.72
Rate for Payer: Hawaii Medical Service Association Commercial	$27.79
Rate for Payer: Hawaii Medical Service Association Medicare	$73.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.26
Rate for Payer: Hawaii Western Management Group Commercial	$22.23
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Humana Medicare	$73.00
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: Kaiser Permanente Medicare	$73.00
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: Ohana Health Plan Medicaid	$73.00
Rate for Payer: Ohana Health Plan Medicare	$73.00
Rate for Payer: UnitedHealthcare Medicaid	$30.72
Rate for Payer: UnitedHealthcare Medicare	$73.00
Rate for Payer: University Health Alliance Commercial	$57.48

DIABETES WITH CC

Facility

$16,062.48

Service Code	MSDRG 638
Min. Negotiated Rate	$16,062.48
Max. Negotiated Rate	$16,062.48
Rate for Payer: Hawaii Medical Service Association Commercial	$16,062.48

DIABETES WITH MCC

Facility

$16,215.46

Service Code	MSDRG 637
Min. Negotiated Rate	$16,215.46
Max. Negotiated Rate	$16,215.46
Rate for Payer: Hawaii Medical Service Association Commercial	$16,215.46

DIABETES WITHOUT CC/MCC

Facility

$15,935.00

Service Code	MSDRG 639
Min. Negotiated Rate	$15,935.00
Max. Negotiated Rate	$15,935.00
Rate for Payer: Hawaii Medical Service Association Commercial	$15,935.00

diazepam 10mg/2 ml syringe [HHSC]

Facility

$141.63

Service Code	HCPCS J3360
Hospital Charge Code	2500243
Hospital Revenue Code	636
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$137.38
Rate for Payer: AlohaCare Medicaid	$70.81
Rate for Payer: AlohaCare Medicaid	$93.50
Rate for Payer: AlohaCare Medicaid	$70.80
Rate for Payer: AlohaCare Medicare	$93.50
Rate for Payer: AlohaCare Medicare	$70.80
Rate for Payer: AlohaCare Medicare	$70.81
Rate for Payer: Cash Price	$92.03
Rate for Payer: Cash Price	$121.54
Rate for Payer: Cash Price	$92.03
Rate for Payer: Cash Price	$121.54
Rate for Payer: Cash Price	$92.06
Rate for Payer: Cash Price	$92.06
Rate for Payer: Devoted Health Medicare	$102.84
Rate for Payer: Devoted Health Medicare	$77.90
Rate for Payer: Devoted Health Medicare	$77.87
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Medicare	$70.81
Rate for Payer: Hawaii Medical Service Association Medicare	$93.50
Rate for Payer: Hawaii Medical Service Association Medicare	$70.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.17
Rate for Payer: Hawaii Western Management Group Commercial	$177.64
Rate for Payer: Hawaii Western Management Group Commercial	$134.51
Rate for Payer: Hawaii Western Management Group Commercial	$134.55
Rate for Payer: Health Management Network Commercial	$120.35
Rate for Payer: Health Management Network Commercial	$120.39
Rate for Payer: Health Management Network Commercial	$158.94
Rate for Payer: Humana Medicare	$70.81
Rate for Payer: Humana Medicare	$70.80
Rate for Payer: Humana Medicare	$93.50
Rate for Payer: Kaiser Permanente Commercial	$127.47
Rate for Payer: Kaiser Permanente Commercial	$168.29
Rate for Payer: Kaiser Permanente Commercial	$127.43
Rate for Payer: Kaiser Permanente Medicaid	$72.23
Rate for Payer: Kaiser Permanente Medicaid	$95.36
Rate for Payer: Kaiser Permanente Medicaid	$72.21
Rate for Payer: Kaiser Permanente Medicare	$70.81
Rate for Payer: Kaiser Permanente Medicare	$70.80
Rate for Payer: Kaiser Permanente Medicare	$93.50
Rate for Payer: MDX Hawaii PPO	$181.38
Rate for Payer: MDX Hawaii PPO	$137.34
Rate for Payer: MDX Hawaii PPO	$137.38
Rate for Payer: Ohana Health Plan Medicaid	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$93.50
Rate for Payer: Ohana Health Plan Medicaid	$70.80
Rate for Payer: Ohana Health Plan Medicare	$93.50
Rate for Payer: Ohana Health Plan Medicare	$70.80
Rate for Payer: Ohana Health Plan Medicare	$70.81
Rate for Payer: UnitedHealthcare Medicaid	$84.95
Rate for Payer: UnitedHealthcare Medicaid	$84.98
Rate for Payer: UnitedHealthcare Medicaid	$112.19
Rate for Payer: UnitedHealthcare Medicare	$70.80
Rate for Payer: UnitedHealthcare Medicare	$93.50
Rate for Payer: UnitedHealthcare Medicare	$70.81
Rate for Payer: University Health Alliance Commercial	$136.30
Rate for Payer: University Health Alliance Commercial	$103.23
Rate for Payer: University Health Alliance Commercial	$103.20

diazepam 10mg/2 ml syringe [HHSC]

Facility

$141.63

Service Code	HCPCS J3360
Hospital Charge Code	2500243
Hospital Revenue Code	250
Min. Negotiated Rate	$120.39
Max. Negotiated Rate	$137.38
Rate for Payer: Cash Price	$92.06
Rate for Payer: Cash Price	$92.03
Rate for Payer: Cash Price	$121.54
Rate for Payer: Health Management Network Commercial	$158.94
Rate for Payer: Health Management Network Commercial	$120.35
Rate for Payer: Health Management Network Commercial	$120.39
Rate for Payer: Kaiser Permanente Commercial	$168.29
Rate for Payer: Kaiser Permanente Commercial	$127.43
Rate for Payer: Kaiser Permanente Commercial	$127.47
Rate for Payer: MDX Hawaii PPO	$137.38
Rate for Payer: MDX Hawaii PPO	$137.34
Rate for Payer: MDX Hawaii PPO	$181.38

diazepam 5-7.5-10 mg rectal kit [HHSC]

Facility

$622.44

Service Code	NDC 68682065220
Hospital Charge Code	2500241
Hospital Revenue Code	250
Min. Negotiated Rate	$311.22
Max. Negotiated Rate	$603.77
Rate for Payer: AlohaCare Medicaid	$311.22
Rate for Payer: AlohaCare Medicare	$311.22
Rate for Payer: Cash Price	$404.59
Rate for Payer: Devoted Health Medicare	$342.34
Rate for Payer: Hawaii Medical Service Association Medicare	$311.22
Rate for Payer: Hawaii Western Management Group Commercial	$591.32
Rate for Payer: Health Management Network Commercial	$529.07
Rate for Payer: Humana Medicare	$311.22
Rate for Payer: Kaiser Permanente Commercial	$560.20
Rate for Payer: Kaiser Permanente Medicaid	$317.44
Rate for Payer: Kaiser Permanente Medicare	$311.22
Rate for Payer: MDX Hawaii PPO	$603.77
Rate for Payer: Ohana Health Plan Medicaid	$311.22
Rate for Payer: Ohana Health Plan Medicare	$311.22
Rate for Payer: UnitedHealthcare Medicaid	$373.46
Rate for Payer: UnitedHealthcare Medicare	$311.22
Rate for Payer: University Health Alliance Commercial	$453.70

diazepam 5-7.5-10 mg rectal kit [HHSC]

Facility

$622.44

Service Code	NDC 68682065220
Hospital Charge Code	2500241
Hospital Revenue Code	250
Min. Negotiated Rate	$529.07
Max. Negotiated Rate	$603.77
Rate for Payer: Cash Price	$404.59
Rate for Payer: Health Management Network Commercial	$529.07
Rate for Payer: Kaiser Permanente Commercial	$560.20
Rate for Payer: MDX Hawaii PPO	$603.77

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079028520
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51862006301
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 51079028520
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00172392660
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00172392660
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904588061
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00378034501
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00378034501
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

diazepam 5 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00904588061
Hospital Charge Code	2500242
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

Know your out-of-pocket cost for care.

All Charges