|
diazepam 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51862006301
|
| 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
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
OP
|
$303.49
|
|
|
Service Code
|
NDC 21922000909
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$151.75 |
| Max. Negotiated Rate |
$294.39 |
| Rate for Payer: AlohaCare Medicaid |
$151.75
|
| Rate for Payer: AlohaCare Medicare |
$151.75
|
| Rate for Payer: Cash Price |
$197.27
|
| Rate for Payer: Devoted Health Medicare |
$166.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$151.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$288.32
|
| Rate for Payer: Health Management Network Commercial |
$257.97
|
| Rate for Payer: Humana Medicare |
$151.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$154.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$151.75
|
| Rate for Payer: MDX Hawaii PPO |
$294.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$151.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$151.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$182.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$151.75
|
| Rate for Payer: University Health Alliance Commercial |
$221.21
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
OP
|
$86.49
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.24 |
| Max. Negotiated Rate |
$83.90 |
| Rate for Payer: AlohaCare Medicaid |
$43.24
|
| Rate for Payer: AlohaCare Medicare |
$43.24
|
| Rate for Payer: Cash Price |
$56.22
|
| Rate for Payer: Devoted Health Medicare |
$47.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.17
|
| Rate for Payer: Health Management Network Commercial |
$73.52
|
| Rate for Payer: Humana Medicare |
$43.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.24
|
| Rate for Payer: MDX Hawaii PPO |
$83.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.24
|
| Rate for Payer: University Health Alliance Commercial |
$63.04
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
OP
|
$78.26
|
|
|
Service Code
|
NDC 43598097710
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$75.91 |
| Rate for Payer: AlohaCare Medicaid |
$39.13
|
| Rate for Payer: AlohaCare Medicare |
$39.13
|
| Rate for Payer: Cash Price |
$50.87
|
| Rate for Payer: Devoted Health Medicare |
$43.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.35
|
| Rate for Payer: Health Management Network Commercial |
$66.52
|
| Rate for Payer: Humana Medicare |
$39.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.13
|
| Rate for Payer: MDX Hawaii PPO |
$75.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.13
|
| Rate for Payer: University Health Alliance Commercial |
$57.04
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
IP
|
$80.81
|
|
|
Service Code
|
NDC 46122075252
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.69 |
| Max. Negotiated Rate |
$78.39 |
| Rate for Payer: Cash Price |
$52.53
|
| Rate for Payer: Health Management Network Commercial |
$68.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.73
|
| Rate for Payer: MDX Hawaii PPO |
$78.39
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
IP
|
$303.49
|
|
|
Service Code
|
NDC 21922000909
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.97 |
| Max. Negotiated Rate |
$294.39 |
| Rate for Payer: Cash Price |
$197.27
|
| Rate for Payer: Health Management Network Commercial |
$257.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.14
|
| Rate for Payer: MDX Hawaii PPO |
$294.39
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
OP
|
$283.55
|
|
|
Service Code
|
NDC 69097052444
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.78 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: AlohaCare Medicaid |
$141.78
|
| Rate for Payer: AlohaCare Medicare |
$141.78
|
| Rate for Payer: Cash Price |
$184.31
|
| Rate for Payer: Devoted Health Medicare |
$155.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$141.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.37
|
| Rate for Payer: Health Management Network Commercial |
$241.02
|
| Rate for Payer: Humana Medicare |
$141.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.61
|
| Rate for Payer: Kaiser Permanente Medicare |
$141.78
|
| Rate for Payer: MDX Hawaii PPO |
$275.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$141.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$141.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$170.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$141.78
|
| Rate for Payer: University Health Alliance Commercial |
$206.68
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
IP
|
$86.49
|
|
|
Service Code
|
NDC 00067815203
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.52 |
| Max. Negotiated Rate |
$83.90 |
| Rate for Payer: Cash Price |
$56.22
|
| Rate for Payer: Health Management Network Commercial |
$73.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.84
|
| Rate for Payer: MDX Hawaii PPO |
$83.90
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
OP
|
$80.81
|
|
|
Service Code
|
NDC 46122075252
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.41 |
| Max. Negotiated Rate |
$78.39 |
| Rate for Payer: AlohaCare Medicaid |
$40.41
|
| Rate for Payer: AlohaCare Medicare |
$40.41
|
| Rate for Payer: Cash Price |
$52.53
|
| Rate for Payer: Devoted Health Medicare |
$44.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.77
|
| Rate for Payer: Health Management Network Commercial |
$68.69
|
| Rate for Payer: Humana Medicare |
$40.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.41
|
| Rate for Payer: MDX Hawaii PPO |
$78.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.41
|
| Rate for Payer: University Health Alliance Commercial |
$58.90
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
IP
|
$78.26
|
|
|
Service Code
|
NDC 43598097710
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.52 |
| Max. Negotiated Rate |
$75.91 |
| Rate for Payer: Cash Price |
$50.87
|
| Rate for Payer: Health Management Network Commercial |
$66.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.43
|
| Rate for Payer: MDX Hawaii PPO |
$75.91
|
|
|
diclofenac 1% topical gel 100 gm [HHSC]
|
Facility
|
IP
|
$283.55
|
|
|
Service Code
|
NDC 69097052444
|
| Hospital Charge Code |
2501097
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.02 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: Cash Price |
$184.31
|
| Rate for Payer: Health Management Network Commercial |
$241.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.19
|
| Rate for Payer: MDX Hawaii PPO |
$275.04
|
|
|
dicyclomine 20mg/2ml injection [HHSC]
|
Facility
|
OP
|
$221.92
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2500245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.68 |
| Max. Negotiated Rate |
$215.26 |
| Rate for Payer: AlohaCare Medicaid |
$110.96
|
| Rate for Payer: AlohaCare Medicaid |
$217.53
|
| Rate for Payer: AlohaCare Medicaid |
$106.89
|
| Rate for Payer: AlohaCare Medicaid |
$70.77
|
| Rate for Payer: AlohaCare Medicare |
$70.77
|
| Rate for Payer: AlohaCare Medicare |
$106.89
|
| Rate for Payer: AlohaCare Medicare |
$110.96
|
| Rate for Payer: AlohaCare Medicare |
$217.53
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$144.25
|
| Rate for Payer: Cash Price |
$138.95
|
| Rate for Payer: Cash Price |
$138.95
|
| Rate for Payer: Cash Price |
$144.25
|
| Rate for Payer: Cash Price |
$282.79
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$282.79
|
| Rate for Payer: Devoted Health Medicare |
$117.57
|
| Rate for Payer: Devoted Health Medicare |
$122.06
|
| Rate for Payer: Devoted Health Medicare |
$77.85
|
| Rate for Payer: Devoted Health Medicare |
$239.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$106.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$217.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$210.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$134.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$203.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$413.31
|
| Rate for Payer: Health Management Network Commercial |
$369.80
|
| Rate for Payer: Health Management Network Commercial |
$181.70
|
| Rate for Payer: Health Management Network Commercial |
$120.31
|
| Rate for Payer: Health Management Network Commercial |
$188.63
|
| Rate for Payer: Humana Medicare |
$106.89
|
| Rate for Payer: Humana Medicare |
$70.77
|
| Rate for Payer: Humana Medicare |
$110.96
|
| Rate for Payer: Humana Medicare |
$217.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$199.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$391.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$72.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$113.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$221.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$217.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.77
|
| Rate for Payer: MDX Hawaii PPO |
$422.01
|
| Rate for Payer: MDX Hawaii PPO |
$215.26
|
| Rate for Payer: MDX Hawaii PPO |
$207.36
|
| Rate for Payer: MDX Hawaii PPO |
$137.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$217.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$217.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$128.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$133.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$261.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$217.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.77
|
| Rate for Payer: University Health Alliance Commercial |
$317.12
|
| Rate for Payer: University Health Alliance Commercial |
$161.76
|
| Rate for Payer: University Health Alliance Commercial |
$103.17
|
| Rate for Payer: University Health Alliance Commercial |
$155.82
|
|
|
dicyclomine 20mg/2ml injection [HHSC]
|
Facility
|
IP
|
$213.77
|
|
|
Service Code
|
HCPCS J0500
|
| Hospital Charge Code |
2500245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.70 |
| Max. Negotiated Rate |
$207.36 |
| Rate for Payer: Cash Price |
$138.95
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cash Price |
$282.79
|
| Rate for Payer: Cash Price |
$144.25
|
| Rate for Payer: Health Management Network Commercial |
$120.31
|
| Rate for Payer: Health Management Network Commercial |
$181.70
|
| Rate for Payer: Health Management Network Commercial |
$188.63
|
| Rate for Payer: Health Management Network Commercial |
$369.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$127.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$391.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$199.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$192.39
|
| Rate for Payer: MDX Hawaii PPO |
$137.29
|
| Rate for Payer: MDX Hawaii PPO |
$215.26
|
| Rate for Payer: MDX Hawaii PPO |
$422.01
|
| Rate for Payer: MDX Hawaii PPO |
$207.36
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 59651072001
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Health Management Network Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$3.13
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.23
|
|
|
Service Code
|
NDC 00527128201
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Health Management Network Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$3.13
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 00591079501
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
NDC 00527128201
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: AlohaCare Medicaid |
$1.61
|
| Rate for Payer: AlohaCare Medicare |
$1.61
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Devoted Health Medicare |
$1.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network Commercial |
$2.75
|
| Rate for Payer: Humana Medicare |
$1.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.61
|
| Rate for Payer: MDX Hawaii PPO |
$3.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.61
|
| Rate for Payer: University Health Alliance Commercial |
$2.35
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 60687038001
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.58 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Health Management Network Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.73
|
| Rate for Payer: MDX Hawaii PPO |
$2.94
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 60687038001
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.51
|
| Rate for Payer: AlohaCare Medicare |
$1.51
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Devoted Health Medicare |
$1.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.88
|
| Rate for Payer: Health Management Network Commercial |
$2.58
|
| Rate for Payer: Humana Medicare |
$1.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.51
|
| Rate for Payer: MDX Hawaii PPO |
$2.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.51
|
| Rate for Payer: University Health Alliance Commercial |
$2.21
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 00591079501
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: AlohaCare Medicaid |
$2.16
|
| Rate for Payer: AlohaCare Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.10
|
| Rate for Payer: Health Management Network Commercial |
$3.67
|
| Rate for Payer: Humana Medicare |
$2.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.16
|
| Rate for Payer: MDX Hawaii PPO |
$4.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.16
|
| Rate for Payer: University Health Alliance Commercial |
$3.15
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.23
|
|
|
Service Code
|
NDC 59651072001
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: AlohaCare Medicaid |
$1.61
|
| Rate for Payer: AlohaCare Medicare |
$1.61
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Devoted Health Medicare |
$1.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.07
|
| Rate for Payer: Health Management Network Commercial |
$2.75
|
| Rate for Payer: Humana Medicare |
$1.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.61
|
| Rate for Payer: MDX Hawaii PPO |
$3.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.61
|
| Rate for Payer: University Health Alliance Commercial |
$2.35
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.32
|
|
|
Service Code
|
NDC 51079011920
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: AlohaCare Medicaid |
$1.66
|
| Rate for Payer: AlohaCare Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Devoted Health Medicare |
$1.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.15
|
| Rate for Payer: Health Management Network Commercial |
$2.82
|
| Rate for Payer: Humana Medicare |
$1.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.66
|
| Rate for Payer: MDX Hawaii PPO |
$3.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.66
|
| Rate for Payer: University Health Alliance Commercial |
$2.42
|
|
|
dicyclomine 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.32
|
|
|
Service Code
|
NDC 51079011920
|
| Hospital Charge Code |
2500246
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Health Management Network Commercial |
$2.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.99
|
| Rate for Payer: MDX Hawaii PPO |
$3.22
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$58,768.28
|
|
|
Service Code
|
MSDRG 375
|
| Min. Negotiated Rate |
$58,768.28 |
| Max. Negotiated Rate |
$58,768.28 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$58,768.28
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$60,170.56
|
|
|
Service Code
|
MSDRG 374
|
| Min. Negotiated Rate |
$60,170.56 |
| Max. Negotiated Rate |
$60,170.56 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$60,170.56
|
|
