|
diltiazem 30 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 63739007910
|
| Hospital Charge Code |
2500255
|
|
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
|
|
|
diltiazem 30 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 63739007910
|
| Hospital Charge Code |
2500255
|
|
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
|
|
|
diltiazem 30 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079074520
|
| Hospital Charge Code |
2500255
|
|
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
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687057301
|
| Hospital Charge Code |
2500258
|
|
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
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
OP
|
$8.71
|
|
|
Service Code
|
NDC 68682000710
|
| Hospital Charge Code |
2500258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: AlohaCare Medicaid |
$4.36
|
| Rate for Payer: AlohaCare Medicare |
$4.36
|
| Rate for Payer: Cash Price |
$5.66
|
| Rate for Payer: Devoted Health Medicare |
$4.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.27
|
| Rate for Payer: Health Management Network Commercial |
$7.40
|
| Rate for Payer: Humana Medicare |
$4.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.36
|
| Rate for Payer: MDX Hawaii PPO |
$8.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.36
|
| Rate for Payer: University Health Alliance Commercial |
$6.35
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
OP
|
$3.38
|
|
|
Service Code
|
NDC 60687072801
|
| Hospital Charge Code |
2500258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: AlohaCare Medicaid |
$1.69
|
| Rate for Payer: AlohaCare Medicare |
$1.69
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Devoted Health Medicare |
$1.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.21
|
| Rate for Payer: Health Management Network Commercial |
$2.87
|
| Rate for Payer: Humana Medicare |
$1.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.69
|
| Rate for Payer: MDX Hawaii PPO |
$3.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.69
|
| Rate for Payer: University Health Alliance Commercial |
$2.46
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
OP
|
$3.91
|
|
|
Service Code
|
NDC 51079074620
|
| Hospital Charge Code |
2500258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.79 |
| Rate for Payer: AlohaCare Medicaid |
$1.96
|
| Rate for Payer: AlohaCare Medicare |
$1.96
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Devoted Health Medicare |
$2.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.71
|
| Rate for Payer: Health Management Network Commercial |
$3.32
|
| Rate for Payer: Humana Medicare |
$1.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.96
|
| Rate for Payer: MDX Hawaii PPO |
$3.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.96
|
| Rate for Payer: University Health Alliance Commercial |
$2.85
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687057301
|
| Hospital Charge Code |
2500258
|
|
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
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
IP
|
$8.71
|
|
|
Service Code
|
NDC 68682000710
|
| Hospital Charge Code |
2500258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.40 |
| Max. Negotiated Rate |
$8.45 |
| Rate for Payer: Cash Price |
$5.66
|
| Rate for Payer: Health Management Network Commercial |
$7.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.84
|
| Rate for Payer: MDX Hawaii PPO |
$8.45
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
IP
|
$3.91
|
|
|
Service Code
|
NDC 51079074620
|
| Hospital Charge Code |
2500258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$3.79 |
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Health Management Network Commercial |
$3.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.52
|
| Rate for Payer: MDX Hawaii PPO |
$3.79
|
|
|
diltiazem 60 mg tablet [HHSC]
|
Facility
|
IP
|
$3.38
|
|
|
Service Code
|
NDC 60687072801
|
| Hospital Charge Code |
2500258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Health Management Network Commercial |
$2.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.28
|
|
|
diltiazem ER 120 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
2500252
|
|
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
|
|
|
diltiazem ER 120 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
2500252
|
|
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
|
|
|
diltiazem ER 180 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687020601
|
| Hospital Charge Code |
2500253
|
|
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
|
|
|
diltiazem ER 180 mg capsule [HHSC]
|
Facility
|
IP
|
$8.04
|
|
|
Service Code
|
NDC 50742024990
|
| Hospital Charge Code |
2500253
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.83 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Health Management Network Commercial |
$6.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.24
|
| Rate for Payer: MDX Hawaii PPO |
$7.80
|
|
|
diltiazem ER 180 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687020601
|
| Hospital Charge Code |
2500253
|
|
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
|
|
|
diltiazem ER 180 mg capsule [HHSC]
|
Facility
|
OP
|
$8.04
|
|
|
Service Code
|
NDC 50742024990
|
| Hospital Charge Code |
2500253
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: AlohaCare Medicaid |
$4.02
|
| Rate for Payer: AlohaCare Medicare |
$4.02
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.64
|
| Rate for Payer: Health Management Network Commercial |
$6.83
|
| Rate for Payer: Humana Medicare |
$4.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.02
|
| Rate for Payer: MDX Hawaii PPO |
$7.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.02
|
| Rate for Payer: University Health Alliance Commercial |
$5.86
|
|
|
diltiazem ER 240 mg capsule [HHSC]
|
Facility
|
IP
|
$11.40
|
|
|
Service Code
|
NDC 50742025090
|
| Hospital Charge Code |
2500254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$11.06 |
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: Health Management Network Commercial |
$9.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.26
|
| Rate for Payer: MDX Hawaii PPO |
$11.06
|
|
|
diltiazem ER 240 mg capsule [HHSC]
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 60687021701
|
| Hospital Charge Code |
2500254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.80 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Health Management Network Commercial |
$3.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.02
|
| Rate for Payer: MDX Hawaii PPO |
$4.34
|
|
|
diltiazem ER 240 mg capsule [HHSC]
|
Facility
|
OP
|
$11.40
|
|
|
Service Code
|
NDC 50742025090
|
| Hospital Charge Code |
2500254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$11.06 |
| Rate for Payer: AlohaCare Medicaid |
$5.70
|
| Rate for Payer: AlohaCare Medicare |
$5.70
|
| Rate for Payer: Cash Price |
$7.41
|
| Rate for Payer: Devoted Health Medicare |
$6.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.83
|
| Rate for Payer: Health Management Network Commercial |
$9.69
|
| Rate for Payer: Humana Medicare |
$5.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.70
|
| Rate for Payer: MDX Hawaii PPO |
$11.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.70
|
| Rate for Payer: University Health Alliance Commercial |
$8.31
|
|
|
diltiazem ER 240 mg capsule [HHSC]
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 60687021701
|
| Hospital Charge Code |
2500254
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: AlohaCare Medicaid |
$2.23
|
| Rate for Payer: AlohaCare Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$2.91
|
| Rate for Payer: Devoted Health Medicare |
$2.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$3.80
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.23
|
| Rate for Payer: MDX Hawaii PPO |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.23
|
| Rate for Payer: University Health Alliance Commercial |
$3.26
|
|
|
diphenhydrAMINE 12.5 mg/5 ml 60ml [HHSC]
|
Facility
|
IP
|
$12.67
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2500259
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$12.29 |
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Health Management Network Commercial |
$3.30
|
| Rate for Payer: Health Management Network Commercial |
$10.61
|
| Rate for Payer: Health Management Network Commercial |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$3.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.58
|
| Rate for Payer: MDX Hawaii PPO |
$3.86
|
| Rate for Payer: MDX Hawaii PPO |
$12.29
|
| Rate for Payer: MDX Hawaii PPO |
$12.11
|
| Rate for Payer: MDX Hawaii PPO |
$3.76
|
|
|
diphenhydrAMINE 12.5 mg/5 ml 60ml [HHSC]
|
Facility
|
OP
|
$12.67
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2500259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$12.29 |
| Rate for Payer: AlohaCare Medicaid |
$6.33
|
| Rate for Payer: AlohaCare Medicaid |
$1.99
|
| Rate for Payer: AlohaCare Medicaid |
$6.24
|
| Rate for Payer: AlohaCare Medicaid |
$1.94
|
| Rate for Payer: AlohaCare Medicare |
$6.33
|
| Rate for Payer: AlohaCare Medicare |
$1.94
|
| Rate for Payer: AlohaCare Medicare |
$1.99
|
| Rate for Payer: AlohaCare Medicare |
$6.24
|
| Rate for Payer: Cash Price |
$8.24
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$8.11
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Devoted Health Medicare |
$2.19
|
| Rate for Payer: Devoted Health Medicare |
$2.13
|
| Rate for Payer: Devoted Health Medicare |
$6.86
|
| Rate for Payer: Devoted Health Medicare |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.69
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.78
|
| Rate for Payer: Health Management Network Commercial |
$10.61
|
| Rate for Payer: Health Management Network Commercial |
$10.77
|
| Rate for Payer: Health Management Network Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$3.30
|
| Rate for Payer: Humana Medicare |
$1.99
|
| Rate for Payer: Humana Medicare |
$1.94
|
| Rate for Payer: Humana Medicare |
$6.24
|
| Rate for Payer: Humana Medicare |
$6.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.24
|
| Rate for Payer: MDX Hawaii PPO |
$12.11
|
| Rate for Payer: MDX Hawaii PPO |
$12.29
|
| Rate for Payer: MDX Hawaii PPO |
$3.86
|
| Rate for Payer: MDX Hawaii PPO |
$3.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.99
|
| Rate for Payer: University Health Alliance Commercial |
$9.10
|
| Rate for Payer: University Health Alliance Commercial |
$9.24
|
| Rate for Payer: University Health Alliance Commercial |
$2.83
|
| Rate for Payer: University Health Alliance Commercial |
$2.90
|
|
|
diphenhydrAMINE 12.5 mg/5 ml cup [HHSC]
|
Facility
|
OP
|
$13.68
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2500260
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$13.27 |
| Rate for Payer: AlohaCare Medicaid |
$6.84
|
| Rate for Payer: AlohaCare Medicaid |
$4.75
|
| Rate for Payer: AlohaCare Medicaid |
$5.34
|
| Rate for Payer: AlohaCare Medicaid |
$4.17
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: AlohaCare Medicare |
$4.17
|
| Rate for Payer: AlohaCare Medicare |
$4.75
|
| Rate for Payer: AlohaCare Medicare |
$5.34
|
| Rate for Payer: Cash Price |
$8.89
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Devoted Health Medicare |
$5.23
|
| Rate for Payer: Devoted Health Medicare |
$4.59
|
| Rate for Payer: Devoted Health Medicare |
$5.87
|
| Rate for Payer: Devoted Health Medicare |
$7.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.03
|
| Rate for Payer: Health Management Network Commercial |
$9.08
|
| Rate for Payer: Health Management Network Commercial |
$11.63
|
| Rate for Payer: Health Management Network Commercial |
$8.08
|
| Rate for Payer: Health Management Network Commercial |
$7.09
|
| Rate for Payer: Humana Medicare |
$4.75
|
| Rate for Payer: Humana Medicare |
$4.17
|
| Rate for Payer: Humana Medicare |
$5.34
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.34
|
| Rate for Payer: MDX Hawaii PPO |
$10.36
|
| Rate for Payer: MDX Hawaii PPO |
$13.27
|
| Rate for Payer: MDX Hawaii PPO |
$9.22
|
| Rate for Payer: MDX Hawaii PPO |
$8.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.75
|
| Rate for Payer: University Health Alliance Commercial |
$7.78
|
| Rate for Payer: University Health Alliance Commercial |
$9.97
|
| Rate for Payer: University Health Alliance Commercial |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$6.93
|
|
|
diphenhydrAMINE 12.5 mg/5 ml cup [HHSC]
|
Facility
|
IP
|
$13.68
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2500260
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.63 |
| Max. Negotiated Rate |
$13.27 |
| Rate for Payer: Cash Price |
$8.89
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cash Price |
$6.94
|
| Rate for Payer: Health Management Network Commercial |
$7.09
|
| Rate for Payer: Health Management Network Commercial |
$9.08
|
| Rate for Payer: Health Management Network Commercial |
$11.63
|
| Rate for Payer: Health Management Network Commercial |
$8.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.56
|
| Rate for Payer: MDX Hawaii PPO |
$9.22
|
| Rate for Payer: MDX Hawaii PPO |
$13.27
|
| Rate for Payer: MDX Hawaii PPO |
$10.36
|
| Rate for Payer: MDX Hawaii PPO |
$8.09
|
|
