|
nicotine 21 mg/24 hr patch [HHSC]
|
Facility
|
OP
|
$11.68
|
|
|
Service Code
|
NDC 46122035374
|
| Hospital Charge Code |
2500581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: AlohaCare Medicaid |
$5.84
|
| Rate for Payer: AlohaCare Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Devoted Health Medicare |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.10
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Humana Medicare |
$5.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.84
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.84
|
| Rate for Payer: University Health Alliance Commercial |
$8.51
|
|
|
nicotine 21 mg/24 hr patch [HHSC]
|
Facility
|
IP
|
$11.86
|
|
|
Service Code
|
NDC 43598044874
|
| Hospital Charge Code |
2500581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$11.50 |
| Rate for Payer: Cash Price |
$7.71
|
| Rate for Payer: Health Management Network Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.67
|
| Rate for Payer: MDX Hawaii PPO |
$11.50
|
|
|
nicotine 21 mg/24 hr patch [HHSC]
|
Facility
|
IP
|
$11.91
|
|
|
Service Code
|
NDC 00536589688
|
| Hospital Charge Code |
2500581
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$11.55 |
| Rate for Payer: Cash Price |
$7.74
|
| Rate for Payer: Health Management Network Commercial |
$10.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.55
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
OP
|
$7.05
|
|
|
Service Code
|
NDC 60687042501
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: AlohaCare Medicaid |
$3.52
|
| Rate for Payer: AlohaCare Medicare |
$3.52
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Devoted Health Medicare |
$3.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.70
|
| Rate for Payer: Health Management Network Commercial |
$5.99
|
| Rate for Payer: Humana Medicare |
$3.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.52
|
| Rate for Payer: MDX Hawaii PPO |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.52
|
| Rate for Payer: University Health Alliance Commercial |
$5.14
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
OP
|
$6.97
|
|
|
Service Code
|
NDC 68084002201
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$6.76 |
| Rate for Payer: AlohaCare Medicaid |
$3.48
|
| Rate for Payer: AlohaCare Medicare |
$3.48
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Devoted Health Medicare |
$3.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.62
|
| Rate for Payer: Health Management Network Commercial |
$5.92
|
| Rate for Payer: Humana Medicare |
$3.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.48
|
| Rate for Payer: MDX Hawaii PPO |
$6.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.08
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
IP
|
$7.05
|
|
|
Service Code
|
NDC 60687042501
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$6.84 |
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Health Management Network Commercial |
$5.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.34
|
| Rate for Payer: MDX Hawaii PPO |
$6.84
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
OP
|
$7.18
|
|
|
Service Code
|
NDC 00904722961
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.59 |
| Max. Negotiated Rate |
$6.96 |
| Rate for Payer: AlohaCare Medicaid |
$3.59
|
| Rate for Payer: AlohaCare Medicare |
$3.59
|
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Devoted Health Medicare |
$3.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.82
|
| Rate for Payer: Health Management Network Commercial |
$6.10
|
| Rate for Payer: Humana Medicare |
$3.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.59
|
| Rate for Payer: MDX Hawaii PPO |
$6.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.59
|
| Rate for Payer: University Health Alliance Commercial |
$5.23
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
IP
|
$7.18
|
|
|
Service Code
|
NDC 00904722961
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.10 |
| Max. Negotiated Rate |
$6.96 |
| Rate for Payer: Cash Price |
$4.67
|
| Rate for Payer: Health Management Network Commercial |
$6.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.46
|
| Rate for Payer: MDX Hawaii PPO |
$6.96
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
OP
|
$5.94
|
|
|
Service Code
|
NDC 69315021101
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.97 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: AlohaCare Medicaid |
$2.97
|
| Rate for Payer: AlohaCare Medicare |
$2.97
|
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Devoted Health Medicare |
$3.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.64
|
| Rate for Payer: Health Management Network Commercial |
$5.05
|
| Rate for Payer: Humana Medicare |
$2.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.97
|
| Rate for Payer: MDX Hawaii PPO |
$5.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.97
|
| Rate for Payer: University Health Alliance Commercial |
$4.33
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
IP
|
$5.94
|
|
|
Service Code
|
NDC 69315021101
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$5.76 |
| Rate for Payer: Cash Price |
$3.86
|
| Rate for Payer: Health Management Network Commercial |
$5.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.35
|
| Rate for Payer: MDX Hawaii PPO |
$5.76
|
|
|
NIFEdipine 10 mg capsule [HHSC]
|
Facility
|
IP
|
$6.97
|
|
|
Service Code
|
NDC 68084002201
|
| Hospital Charge Code |
2500582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$6.76 |
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Health Management Network Commercial |
$5.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.27
|
| Rate for Payer: MDX Hawaii PPO |
$6.76
|
|
|
NIFEdipine ER 30 mg tablet [HHSC]
|
Facility
|
IP
|
$7.75
|
|
|
Service Code
|
NDC 50742062001
|
| Hospital Charge Code |
2500583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$7.52 |
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Health Management Network Commercial |
$6.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.97
|
| Rate for Payer: MDX Hawaii PPO |
$7.52
|
|
|
NIFEdipine ER 30 mg tablet [HHSC]
|
Facility
|
OP
|
$7.75
|
|
|
Service Code
|
NDC 00378035301
|
| Hospital Charge Code |
2500583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$7.52 |
| Rate for Payer: AlohaCare Medicaid |
$3.88
|
| Rate for Payer: AlohaCare Medicare |
$3.88
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Devoted Health Medicare |
$4.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.36
|
| Rate for Payer: Health Management Network Commercial |
$6.59
|
| Rate for Payer: Humana Medicare |
$3.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.88
|
| Rate for Payer: MDX Hawaii PPO |
$7.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$5.65
|
|
|
NIFEdipine ER 30 mg tablet [HHSC]
|
Facility
|
OP
|
$7.75
|
|
|
Service Code
|
NDC 50742062001
|
| Hospital Charge Code |
2500583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$7.52 |
| Rate for Payer: AlohaCare Medicaid |
$3.88
|
| Rate for Payer: AlohaCare Medicare |
$3.88
|
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Devoted Health Medicare |
$4.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.36
|
| Rate for Payer: Health Management Network Commercial |
$6.59
|
| Rate for Payer: Humana Medicare |
$3.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.88
|
| Rate for Payer: MDX Hawaii PPO |
$7.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$5.65
|
|
|
NIFEdipine ER 30 mg tablet [HHSC]
|
Facility
|
IP
|
$7.75
|
|
|
Service Code
|
NDC 00378035301
|
| Hospital Charge Code |
2500583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$7.52 |
| Rate for Payer: Cash Price |
$5.04
|
| Rate for Payer: Health Management Network Commercial |
$6.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.97
|
| Rate for Payer: MDX Hawaii PPO |
$7.52
|
|
|
nirsevimab 50 mg/0.5 mL (private) [HHSC]
|
Facility
|
OP
|
$1,545.53
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
2501182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$600.62 |
| Max. Negotiated Rate |
$1,499.16 |
| Rate for Payer: AlohaCare Medicaid |
$772.76
|
| Rate for Payer: AlohaCare Medicare |
$772.76
|
| Rate for Payer: Cash Price |
$1,004.59
|
| Rate for Payer: Cash Price |
$1,004.59
|
| Rate for Payer: Devoted Health Medicare |
$850.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$600.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$772.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$600.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,468.25
|
| Rate for Payer: Health Management Network Commercial |
$1,313.70
|
| Rate for Payer: Humana Medicare |
$772.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,390.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$788.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$772.76
|
| Rate for Payer: MDX Hawaii PPO |
$1,499.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$772.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$772.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$927.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$772.76
|
| Rate for Payer: University Health Alliance Commercial |
$1,126.54
|
|
|
nirsevimab 50 mg/0.5 mL (private) [HHSC]
|
Facility
|
IP
|
$1,545.53
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
2501182
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,313.70 |
| Max. Negotiated Rate |
$1,499.16 |
| Rate for Payer: Cash Price |
$1,004.59
|
| Rate for Payer: Health Management Network Commercial |
$1,313.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,390.98
|
| Rate for Payer: MDX Hawaii PPO |
$1,499.16
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
IP
|
$9.39
|
|
|
Service Code
|
NDC 13811071910
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.98 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Health Management Network Commercial |
$7.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.45
|
| Rate for Payer: MDX Hawaii PPO |
$9.11
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
OP
|
$22.70
|
|
|
Service Code
|
NDC 70756040411
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.35 |
| Max. Negotiated Rate |
$22.02 |
| Rate for Payer: AlohaCare Medicaid |
$11.35
|
| Rate for Payer: AlohaCare Medicare |
$11.35
|
| Rate for Payer: Cash Price |
$14.76
|
| Rate for Payer: Devoted Health Medicare |
$12.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.57
|
| Rate for Payer: Health Management Network Commercial |
$19.30
|
| Rate for Payer: Humana Medicare |
$11.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.35
|
| Rate for Payer: MDX Hawaii PPO |
$22.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.35
|
| Rate for Payer: University Health Alliance Commercial |
$16.55
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
IP
|
$20.94
|
|
|
Service Code
|
NDC 68001000100
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$20.31 |
| Rate for Payer: Cash Price |
$13.61
|
| Rate for Payer: Health Management Network Commercial |
$17.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.31
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
IP
|
$22.70
|
|
|
Service Code
|
NDC 70756040411
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.30 |
| Max. Negotiated Rate |
$22.02 |
| Rate for Payer: Cash Price |
$14.76
|
| Rate for Payer: Health Management Network Commercial |
$19.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.43
|
| Rate for Payer: MDX Hawaii PPO |
$22.02
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
OP
|
$9.39
|
|
|
Service Code
|
NDC 13811071910
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: AlohaCare Medicaid |
$4.70
|
| Rate for Payer: AlohaCare Medicare |
$4.70
|
| Rate for Payer: Cash Price |
$6.10
|
| Rate for Payer: Devoted Health Medicare |
$5.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.92
|
| Rate for Payer: Health Management Network Commercial |
$7.98
|
| Rate for Payer: Humana Medicare |
$4.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.70
|
| Rate for Payer: MDX Hawaii PPO |
$9.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.70
|
| Rate for Payer: University Health Alliance Commercial |
$6.84
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
OP
|
$23.83
|
|
|
Service Code
|
NDC 60687063365
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.91 |
| Max. Negotiated Rate |
$23.12 |
| Rate for Payer: AlohaCare Medicaid |
$11.91
|
| Rate for Payer: AlohaCare Medicare |
$11.91
|
| Rate for Payer: Cash Price |
$15.49
|
| Rate for Payer: Devoted Health Medicare |
$13.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.64
|
| Rate for Payer: Health Management Network Commercial |
$20.26
|
| Rate for Payer: Humana Medicare |
$11.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.91
|
| Rate for Payer: MDX Hawaii PPO |
$23.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.91
|
| Rate for Payer: University Health Alliance Commercial |
$17.37
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
IP
|
$23.83
|
|
|
Service Code
|
NDC 60687063365
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.26 |
| Max. Negotiated Rate |
$23.12 |
| Rate for Payer: Cash Price |
$15.49
|
| Rate for Payer: Health Management Network Commercial |
$20.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.45
|
| Rate for Payer: MDX Hawaii PPO |
$23.12
|
|
|
nitrofurantoin macr-mon 100 mg capsule [HHSC]
|
Facility
|
OP
|
$14.36
|
|
|
Service Code
|
NDC 68084044601
|
| Hospital Charge Code |
2500585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.18 |
| Max. Negotiated Rate |
$13.93 |
| Rate for Payer: UnitedHealthcare Medicaid |
$8.62
|
| Rate for Payer: AlohaCare Medicaid |
$7.18
|
| Rate for Payer: AlohaCare Medicare |
$7.18
|
| Rate for Payer: Cash Price |
$9.33
|
| Rate for Payer: Devoted Health Medicare |
$7.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.64
|
| Rate for Payer: Health Management Network Commercial |
$12.21
|
| Rate for Payer: Humana Medicare |
$7.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.18
|
| Rate for Payer: MDX Hawaii PPO |
$13.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.18
|
| Rate for Payer: University Health Alliance Commercial |
$10.47
|
|
