|
Methylmalonic Acid Quantitative FSI
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS 83921
|
| Hospital Charge Code |
8117994
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$87.55 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$66.95
|
| 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
|
|
|
methylPRED sod succ 125 mg/ 2ml AOV [HHSC]
|
Facility
|
OP
|
$66.74
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
2500532
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$64.74 |
| Rate for Payer: AlohaCare Medicaid |
$33.37
|
| Rate for Payer: AlohaCare Medicaid |
$29.80
|
| Rate for Payer: AlohaCare Medicare |
$29.80
|
| Rate for Payer: AlohaCare Medicare |
$33.37
|
| Rate for Payer: Cash Price |
$38.74
|
| Rate for Payer: Cash Price |
$38.74
|
| Rate for Payer: Cash Price |
$43.38
|
| Rate for Payer: Cash Price |
$43.38
|
| Rate for Payer: Devoted Health Medicare |
$32.78
|
| Rate for Payer: Devoted Health Medicare |
$36.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.40
|
| Rate for Payer: Health Management Network Commercial |
$50.66
|
| Rate for Payer: Health Management Network Commercial |
$56.73
|
| Rate for Payer: Humana Medicare |
$29.80
|
| Rate for Payer: Humana Medicare |
$33.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.37
|
| Rate for Payer: MDX Hawaii PPO |
$57.81
|
| Rate for Payer: MDX Hawaii PPO |
$64.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.80
|
| Rate for Payer: University Health Alliance Commercial |
$43.44
|
| Rate for Payer: University Health Alliance Commercial |
$48.65
|
|
|
methylPRED sod succ 125 mg/ 2ml AOV [HHSC]
|
Facility
|
IP
|
$59.60
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
2500532
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.66 |
| Max. Negotiated Rate |
$57.81 |
| Rate for Payer: Cash Price |
$38.74
|
| Rate for Payer: Cash Price |
$43.38
|
| Rate for Payer: Health Management Network Commercial |
$56.73
|
| Rate for Payer: Health Management Network Commercial |
$50.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.07
|
| Rate for Payer: MDX Hawaii PPO |
$57.81
|
| Rate for Payer: MDX Hawaii PPO |
$64.74
|
|
|
methylPRED sod succ 1 gm AOV [HHSC]
|
Facility
|
IP
|
$388.23
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
2500531
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$376.58 |
| Rate for Payer: Cash Price |
$252.35
|
| Rate for Payer: Health Management Network Commercial |
$330.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$349.41
|
| Rate for Payer: MDX Hawaii PPO |
$376.58
|
|
|
methylPRED sod succ 1 gm AOV [HHSC]
|
Facility
|
OP
|
$388.23
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
2500531
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$376.58 |
| Rate for Payer: AlohaCare Medicaid |
$194.12
|
| Rate for Payer: AlohaCare Medicare |
$194.12
|
| Rate for Payer: Cash Price |
$252.35
|
| Rate for Payer: Cash Price |
$252.35
|
| Rate for Payer: Devoted Health Medicare |
$213.53
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$368.82
|
| Rate for Payer: Health Management Network Commercial |
$330.00
|
| Rate for Payer: Humana Medicare |
$194.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$349.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$198.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$194.12
|
| Rate for Payer: MDX Hawaii PPO |
$376.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$194.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$232.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.12
|
| Rate for Payer: University Health Alliance Commercial |
$282.98
|
|
|
methylPRED sod succ 40 mg/ 1ml AOV [HHSC]
|
Facility
|
OP
|
$40.60
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
2500534
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$39.38 |
| Rate for Payer: AlohaCare Medicaid |
$20.30
|
| Rate for Payer: AlohaCare Medicaid |
$22.42
|
| Rate for Payer: AlohaCare Medicare |
$22.42
|
| Rate for Payer: AlohaCare Medicare |
$20.30
|
| Rate for Payer: Cash Price |
$29.15
|
| Rate for Payer: Cash Price |
$26.39
|
| Rate for Payer: Cash Price |
$26.39
|
| Rate for Payer: Cash Price |
$29.15
|
| Rate for Payer: Devoted Health Medicare |
$22.33
|
| Rate for Payer: Devoted Health Medicare |
$24.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.60
|
| Rate for Payer: Health Management Network Commercial |
$38.11
|
| Rate for Payer: Health Management Network Commercial |
$34.51
|
| Rate for Payer: Humana Medicare |
$20.30
|
| Rate for Payer: Humana Medicare |
$22.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.42
|
| Rate for Payer: MDX Hawaii PPO |
$39.38
|
| Rate for Payer: MDX Hawaii PPO |
$43.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.42
|
| Rate for Payer: University Health Alliance Commercial |
$29.59
|
| Rate for Payer: University Health Alliance Commercial |
$32.68
|
|
|
methylPRED sod succ 40 mg/ 1ml AOV [HHSC]
|
Facility
|
IP
|
$40.60
|
|
|
Service Code
|
HCPCS J2919
|
| Hospital Charge Code |
2500534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.51 |
| Max. Negotiated Rate |
$39.38 |
| Rate for Payer: Cash Price |
$26.39
|
| Rate for Payer: Cash Price |
$29.15
|
| Rate for Payer: Health Management Network Commercial |
$34.51
|
| Rate for Payer: Health Management Network Commercial |
$38.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.36
|
| Rate for Payer: MDX Hawaii PPO |
$43.49
|
| Rate for Payer: MDX Hawaii PPO |
$39.38
|
|
|
metoclopramide 10 mg/10 mL cup [HHSC]
|
Facility
|
IP
|
$12.37
|
|
|
Service Code
|
NDC 00121157610
|
| Hospital Charge Code |
2500536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Health Management Network Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.13
|
| Rate for Payer: MDX Hawaii PPO |
$12.00
|
|
|
metoclopramide 10 mg/10 mL cup [HHSC]
|
Facility
|
OP
|
$12.37
|
|
|
Service Code
|
NDC 00121157610
|
| Hospital Charge Code |
2500536
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.18 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: AlohaCare Medicaid |
$6.18
|
| Rate for Payer: AlohaCare Medicare |
$6.18
|
| Rate for Payer: Cash Price |
$8.04
|
| Rate for Payer: Devoted Health Medicare |
$6.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.75
|
| Rate for Payer: Health Management Network Commercial |
$10.51
|
| Rate for Payer: Humana Medicare |
$6.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.18
|
| Rate for Payer: MDX Hawaii PPO |
$12.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.18
|
| Rate for Payer: University Health Alliance Commercial |
$9.02
|
|
|
metoclopramide 10 mg/2 ml vial [HHSC]
|
Facility
|
OP
|
$22.37
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
2500537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: AlohaCare Medicaid |
$11.19
|
| Rate for Payer: AlohaCare Medicaid |
$4.01
|
| Rate for Payer: AlohaCare Medicare |
$4.01
|
| Rate for Payer: AlohaCare Medicare |
$11.19
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Devoted Health Medicare |
$12.30
|
| Rate for Payer: Devoted Health Medicare |
$4.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.62
|
| Rate for Payer: Health Management Network Commercial |
$6.82
|
| Rate for Payer: Health Management Network Commercial |
$19.01
|
| Rate for Payer: Humana Medicare |
$4.01
|
| Rate for Payer: Humana Medicare |
$11.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.01
|
| Rate for Payer: MDX Hawaii PPO |
$21.70
|
| Rate for Payer: MDX Hawaii PPO |
$7.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.01
|
| Rate for Payer: University Health Alliance Commercial |
$16.31
|
| Rate for Payer: University Health Alliance Commercial |
$5.85
|
|
|
metoclopramide 10 mg/2 ml vial [HHSC]
|
Facility
|
IP
|
$22.37
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
2500537
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.01 |
| Max. Negotiated Rate |
$21.70 |
| Rate for Payer: Cash Price |
$14.54
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Health Management Network Commercial |
$19.01
|
| Rate for Payer: Health Management Network Commercial |
$6.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.22
|
| Rate for Payer: MDX Hawaii PPO |
$7.78
|
| Rate for Payer: MDX Hawaii PPO |
$21.70
|
|
|
metoclopramide 10 mg tablet [HHSC]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687063101
|
| Hospital Charge Code |
2500535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.60
|
| 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
|
|
|
metoclopramide 10 mg tablet [HHSC]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687063101
|
| Hospital Charge Code |
2500535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$2.00
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Devoted Health Medicare |
$2.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$2.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.00
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.00
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
metoclopramide 10 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084067601
|
| Hospital Charge Code |
2500535
|
|
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
|
|
|
metoclopramide 10 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084067601
|
| Hospital Charge Code |
2500535
|
|
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
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$11.53
|
|
|
Service Code
|
NDC 72888005201
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$11.18 |
| Rate for Payer: AlohaCare Medicaid |
$5.76
|
| Rate for Payer: AlohaCare Medicare |
$5.76
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Devoted Health Medicare |
$6.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.95
|
| Rate for Payer: Health Management Network Commercial |
$9.80
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.76
|
| Rate for Payer: MDX Hawaii PPO |
$11.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.76
|
| Rate for Payer: University Health Alliance Commercial |
$8.40
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$18.27
|
|
|
Service Code
|
NDC 51079002320
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.53 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Health Management Network Commercial |
$15.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.44
|
| Rate for Payer: MDX Hawaii PPO |
$17.72
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$12.65
|
|
|
Service Code
|
NDC 76385013601
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: AlohaCare Medicaid |
$6.33
|
| Rate for Payer: AlohaCare Medicare |
$6.33
|
| Rate for Payer: Cash Price |
$8.22
|
| Rate for Payer: Devoted Health Medicare |
$6.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.02
|
| Rate for Payer: Health Management Network Commercial |
$10.75
|
| Rate for Payer: Humana Medicare |
$6.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.33
|
| Rate for Payer: MDX Hawaii PPO |
$12.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.33
|
| Rate for Payer: University Health Alliance Commercial |
$9.22
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$12.65
|
|
|
Service Code
|
NDC 76385013601
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.75 |
| Max. Negotiated Rate |
$12.27 |
| Rate for Payer: Cash Price |
$8.22
|
| Rate for Payer: Health Management Network Commercial |
$10.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.38
|
| Rate for Payer: MDX Hawaii PPO |
$12.27
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$18.27
|
|
|
Service Code
|
NDC 51079002320
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$17.72 |
| Rate for Payer: AlohaCare Medicaid |
$9.13
|
| Rate for Payer: AlohaCare Medicare |
$9.13
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: Devoted Health Medicare |
$10.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.36
|
| Rate for Payer: Health Management Network Commercial |
$15.53
|
| Rate for Payer: Humana Medicare |
$9.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.13
|
| Rate for Payer: MDX Hawaii PPO |
$17.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.13
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.13
|
| Rate for Payer: University Health Alliance Commercial |
$13.32
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
OP
|
$11.53
|
|
|
Service Code
|
NDC 00185505001
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$11.18 |
| Rate for Payer: AlohaCare Medicaid |
$5.76
|
| Rate for Payer: AlohaCare Medicare |
$5.76
|
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Devoted Health Medicare |
$6.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.95
|
| Rate for Payer: Health Management Network Commercial |
$9.80
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.76
|
| Rate for Payer: MDX Hawaii PPO |
$11.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.76
|
| Rate for Payer: University Health Alliance Commercial |
$8.40
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$11.53
|
|
|
Service Code
|
NDC 72888005201
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$11.18 |
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Health Management Network Commercial |
$9.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.38
|
| Rate for Payer: MDX Hawaii PPO |
$11.18
|
|
|
metolazone 2.5 mg tablet [HHSC]
|
Facility
|
IP
|
$11.53
|
|
|
Service Code
|
NDC 00185505001
|
| Hospital Charge Code |
2500538
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$11.18 |
| Rate for Payer: Cash Price |
$7.49
|
| Rate for Payer: Health Management Network Commercial |
$9.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.38
|
| Rate for Payer: MDX Hawaii PPO |
$11.18
|
|
|
metolazone 5 mg tablet [HHSC]
|
Facility
|
IP
|
$20.76
|
|
|
Service Code
|
NDC 51079002420
|
| Hospital Charge Code |
2500539
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.65 |
| Max. Negotiated Rate |
$20.14 |
| Rate for Payer: Cash Price |
$13.49
|
| Rate for Payer: Health Management Network Commercial |
$17.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.68
|
| Rate for Payer: MDX Hawaii PPO |
$20.14
|
|
|
metolazone 5 mg tablet [HHSC]
|
Facility
|
IP
|
$13.10
|
|
|
Service Code
|
NDC 00185005501
|
| Hospital Charge Code |
2500539
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$12.71 |
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Health Management Network Commercial |
$11.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.79
|
| Rate for Payer: MDX Hawaii PPO |
$12.71
|
|
