|
hydrALAZINE 20 mg/1ml vial [HHSC]
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
2500385
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$22.65 |
| Rate for Payer: AlohaCare Medicaid |
$11.68
|
| Rate for Payer: AlohaCare Medicaid |
$39.17
|
| Rate for Payer: AlohaCare Medicare |
$39.17
|
| Rate for Payer: AlohaCare Medicare |
$11.68
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Devoted Health Medicare |
$12.84
|
| Rate for Payer: Devoted Health Medicare |
$43.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.19
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.42
|
| Rate for Payer: Health Management Network Commercial |
$66.59
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Humana Medicare |
$11.68
|
| Rate for Payer: Humana Medicare |
$39.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.17
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$75.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.17
|
| Rate for Payer: University Health Alliance Commercial |
$17.02
|
| Rate for Payer: University Health Alliance Commercial |
$57.10
|
|
|
hydrALAZINE 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62584073301
|
| Hospital Charge Code |
2500386
|
|
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
|
|
|
hydrALAZINE 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
2500386
|
|
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
|
|
|
hydrALAZINE 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62584073301
|
| Hospital Charge Code |
2500386
|
|
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
|
|
|
hydrALAZINE 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
2500386
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 62584073401
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 62584073401
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687083301
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687083301
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904644261
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrALAZINE 50 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904644261
|
| Hospital Charge Code |
2500387
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687059301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
hydrochlorothiazide 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 16729018301
|
| Hospital Charge Code |
2500388
|
|
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
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
OP
|
$3.47
|
|
|
Service Code
|
NDC 60687039601
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: AlohaCare Medicaid |
$1.74
|
| Rate for Payer: AlohaCare Medicare |
$1.74
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Devoted Health Medicare |
$1.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.30
|
| Rate for Payer: Health Management Network Commercial |
$2.95
|
| Rate for Payer: Humana Medicare |
$1.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.74
|
| Rate for Payer: MDX Hawaii PPO |
$3.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.74
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.74
|
| Rate for Payer: University Health Alliance Commercial |
$2.53
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
OP
|
$3.84
|
|
|
Service Code
|
NDC 00406012301
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: AlohaCare Medicaid |
$1.92
|
| Rate for Payer: AlohaCare Medicare |
$1.92
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Devoted Health Medicare |
$2.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.65
|
| Rate for Payer: Health Management Network Commercial |
$3.26
|
| Rate for Payer: Humana Medicare |
$1.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.92
|
| Rate for Payer: MDX Hawaii PPO |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.92
|
| Rate for Payer: University Health Alliance Commercial |
$2.80
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
IP
|
$3.84
|
|
|
Service Code
|
NDC 00406012301
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.26 |
| Max. Negotiated Rate |
$3.72 |
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Health Management Network Commercial |
$3.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.46
|
| Rate for Payer: MDX Hawaii PPO |
$3.72
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
NDC 68084089509
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: AlohaCare Medicaid |
$1.91
|
| Rate for Payer: AlohaCare Medicare |
$1.91
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Devoted Health Medicare |
$2.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.63
|
| Rate for Payer: Health Management Network Commercial |
$3.25
|
| Rate for Payer: Humana Medicare |
$1.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.91
|
| Rate for Payer: MDX Hawaii PPO |
$3.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.78
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 68084089509
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Health Management Network Commercial |
$3.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.44
|
| Rate for Payer: MDX Hawaii PPO |
$3.71
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 00406012362
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Cash Price |
$2.87
|
| Rate for Payer: Health Management Network Commercial |
$3.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.98
|
| Rate for Payer: MDX Hawaii PPO |
$4.29
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
NDC 68084089501
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Health Management Network Commercial |
$2.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.12
|
| Rate for Payer: MDX Hawaii PPO |
$3.37
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
IP
|
$3.47
|
|
|
Service Code
|
NDC 60687039601
|
| Hospital Charge Code |
2500011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Health Management Network Commercial |
$2.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.12
|
| Rate for Payer: MDX Hawaii PPO |
$3.37
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904682461
|
| Hospital Charge Code |
2500011
|
|
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
|
|
|
HYDROcodone-APAP 5-325 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904682461
|
| Hospital Charge Code |
2500011
|
|
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
|
|
