|
DICLOFENAC SODIUM 1 % TOP GEL
|
Facility
|
OP
|
$121.50
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.75 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: AlohaCare Medicaid |
$60.75
|
| Rate for Payer: AlohaCare Medicaid |
$40.67
|
| Rate for Payer: AlohaCare Medicaid |
$33.84
|
| Rate for Payer: AlohaCare Medicare |
$60.91
|
| Rate for Payer: AlohaCare Medicare |
$109.35
|
| Rate for Payer: AlohaCare Medicare |
$73.22
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Cash Price |
$78.98
|
| Rate for Payer: Cash Price |
$43.99
|
| Rate for Payer: Devoted Health Medicare |
$67.00
|
| Rate for Payer: Devoted Health Medicare |
$120.28
|
| Rate for Payer: Devoted Health Medicare |
$80.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$109.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$115.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.30
|
| Rate for Payer: Health Management Network Commercial |
$103.28
|
| Rate for Payer: Health Management Network Commercial |
$57.53
|
| Rate for Payer: Health Management Network Commercial |
$69.15
|
| Rate for Payer: Humana Medicare |
$60.91
|
| Rate for Payer: Humana Medicare |
$73.22
|
| Rate for Payer: Humana Medicare |
$109.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$109.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.22
|
| Rate for Payer: MDX Hawaii PPO |
$117.86
|
| Rate for Payer: MDX Hawaii PPO |
$65.65
|
| Rate for Payer: MDX Hawaii PPO |
$78.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$109.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$109.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$109.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.91
|
| Rate for Payer: University Health Alliance Commercial |
$49.33
|
| Rate for Payer: University Health Alliance Commercial |
$88.56
|
| Rate for Payer: University Health Alliance Commercial |
$59.30
|
|
|
DICLOFENAC SODIUM 1 % TOP GEL
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.53 |
| Max. Negotiated Rate |
$65.65 |
| Rate for Payer: Cash Price |
$43.99
|
| Rate for Payer: Cash Price |
$78.98
|
| Rate for Payer: Cash Price |
$52.88
|
| Rate for Payer: Health Management Network Commercial |
$69.15
|
| Rate for Payer: Health Management Network Commercial |
$103.28
|
| Rate for Payer: Health Management Network Commercial |
$57.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$109.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.91
|
| Rate for Payer: MDX Hawaii PPO |
$65.65
|
| Rate for Payer: MDX Hawaii PPO |
$117.86
|
| Rate for Payer: MDX Hawaii PPO |
$78.91
|
|
|
DICYCLOMINE 10 MG/ML IM SOLN
|
Facility
|
OP
|
$119.85
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.68 |
| Max. Negotiated Rate |
$118.65 |
| Rate for Payer: AlohaCare Medicaid |
$59.92
|
| Rate for Payer: AlohaCare Medicaid |
$224.10
|
| Rate for Payer: AlohaCare Medicare |
$403.39
|
| Rate for Payer: AlohaCare Medicare |
$107.86
|
| Rate for Payer: Cash Price |
$291.34
|
| Rate for Payer: Cash Price |
$77.90
|
| Rate for Payer: Cash Price |
$77.90
|
| Rate for Payer: Cash Price |
$291.34
|
| Rate for Payer: Devoted Health Medicare |
$118.65
|
| Rate for Payer: Devoted Health Medicare |
$443.73
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$403.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$113.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$425.80
|
| Rate for Payer: Health Management Network Commercial |
$380.98
|
| Rate for Payer: Health Management Network Commercial |
$101.87
|
| Rate for Payer: Humana Medicare |
$107.86
|
| Rate for Payer: Humana Medicare |
$403.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$403.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$228.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$403.39
|
| Rate for Payer: MDX Hawaii PPO |
$116.25
|
| Rate for Payer: MDX Hawaii PPO |
$434.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$403.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$403.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$268.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$403.39
|
| Rate for Payer: University Health Alliance Commercial |
$87.36
|
| Rate for Payer: University Health Alliance Commercial |
$326.70
|
|
|
DICYCLOMINE 10 MG/ML IM SOLN
|
Facility
|
IP
|
$119.85
|
|
|
Service Code
|
HCPCS J0500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.87 |
| Max. Negotiated Rate |
$116.25 |
| Rate for Payer: Cash Price |
$77.90
|
| Rate for Payer: Cash Price |
$291.34
|
| Rate for Payer: Health Management Network Commercial |
$101.87
|
| Rate for Payer: Health Management Network Commercial |
$380.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$403.39
|
| Rate for Payer: MDX Hawaii PPO |
$434.76
|
| Rate for Payer: MDX Hawaii PPO |
$116.25
|
|
|
DICYCLOMINE 10 MG PO CAP
|
Facility
|
IP
|
$2.48
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.11 |
| Max. Negotiated Rate |
$2.41 |
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Health Management Network Commercial |
$2.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.23
|
| Rate for Payer: MDX Hawaii PPO |
$2.41
|
|
|
DICYCLOMINE 10 MG PO CAP
|
Facility
|
OP
|
$2.48
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: AlohaCare Medicaid |
$1.24
|
| Rate for Payer: AlohaCare Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$1.61
|
| 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 |
$2.36
|
| Rate for Payer: Health Management Network Commercial |
$2.11
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.23
|
| Rate for Payer: MDX Hawaii PPO |
$2.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.23
|
| Rate for Payer: University Health Alliance Commercial |
$1.81
|
|
|
DICYCLOMINE 20 MG PO TABLET
|
Facility
|
IP
|
$3.09
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Health Management Network Commercial |
$2.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.89
|
| Rate for Payer: MDX Hawaii PPO |
$3.11
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
|
|
DICYCLOMINE 20 MG PO TABLET
|
Facility
|
OP
|
$3.21
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: AlohaCare Medicaid |
$1.60
|
| Rate for Payer: AlohaCare Medicaid |
$1.54
|
| Rate for Payer: AlohaCare Medicare |
$2.78
|
| Rate for Payer: AlohaCare Medicare |
$2.89
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Devoted Health Medicare |
$3.18
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.05
|
| Rate for Payer: Health Management Network Commercial |
$2.73
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Humana Medicare |
$2.89
|
| Rate for Payer: Humana Medicare |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.89
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
| Rate for Payer: MDX Hawaii PPO |
$3.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.78
|
| Rate for Payer: University Health Alliance Commercial |
$2.34
|
| Rate for Payer: University Health Alliance Commercial |
$2.25
|
|
|
DIGESTIVE MALIGNANCY WITH CC
|
Facility
|
IP
|
$54,633.11
|
|
|
Service Code
|
MSDRG 375
|
| Min. Negotiated Rate |
$54,633.11 |
| Max. Negotiated Rate |
$54,633.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$54,633.11
|
|
|
DIGESTIVE MALIGNANCY WITH MCC
|
Facility
|
IP
|
$55,936.72
|
|
|
Service Code
|
MSDRG 374
|
| Min. Negotiated Rate |
$55,936.72 |
| Max. Negotiated Rate |
$55,936.72 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$55,936.72
|
|
|
DIGESTIVE MALIGNANCY WITHOUT CC/MCC
|
Facility
|
IP
|
$28,489.80
|
|
|
Service Code
|
MSDRG 376
|
| Min. Negotiated Rate |
$28,489.80 |
| Max. Negotiated Rate |
$28,489.80 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28,489.80
|
|
|
DIGOXIN 125 MCG (0.125 MG) PO TABLET
|
Facility
|
IP
|
$8.05
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$7.81 |
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Health Management Network Commercial |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.25
|
| Rate for Payer: MDX Hawaii PPO |
$7.81
|
|
|
DIGOXIN 125 MCG (0.125 MG) PO TABLET
|
Facility
|
OP
|
$8.05
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$7.97 |
| Rate for Payer: AlohaCare Medicaid |
$4.03
|
| Rate for Payer: AlohaCare Medicare |
$7.25
|
| Rate for Payer: Cash Price |
$5.23
|
| Rate for Payer: Devoted Health Medicare |
$7.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$6.84
|
| Rate for Payer: Humana Medicare |
$7.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.25
|
| Rate for Payer: MDX Hawaii PPO |
$7.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.25
|
| Rate for Payer: University Health Alliance Commercial |
$5.87
|
|
|
DIGOXIN 250 MCG (0.25 MG) PO TABLET
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.35 |
| Max. Negotiated Rate |
$12.57 |
| Rate for Payer: AlohaCare Medicaid |
$6.35
|
| Rate for Payer: AlohaCare Medicare |
$11.43
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Devoted Health Medicare |
$12.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.06
|
| Rate for Payer: Health Management Network Commercial |
$10.79
|
| Rate for Payer: Humana Medicare |
$11.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.43
|
| Rate for Payer: MDX Hawaii PPO |
$12.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.43
|
| Rate for Payer: University Health Alliance Commercial |
$9.26
|
|
|
DIGOXIN 250 MCG (0.25 MG) PO TABLET
|
Facility
|
IP
|
$12.70
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.79 |
| Max. Negotiated Rate |
$12.32 |
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Health Management Network Commercial |
$10.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.43
|
| Rate for Payer: MDX Hawaii PPO |
$12.32
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJ SOLN
|
Facility
|
OP
|
$30.36
|
|
|
Service Code
|
HCPCS J1160
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$30.06 |
| Rate for Payer: AlohaCare Medicaid |
$15.18
|
| Rate for Payer: AlohaCare Medicare |
$27.32
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Devoted Health Medicare |
$30.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.84
|
| Rate for Payer: Health Management Network Commercial |
$25.81
|
| Rate for Payer: Humana Medicare |
$27.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.32
|
| Rate for Payer: MDX Hawaii PPO |
$29.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.32
|
| Rate for Payer: University Health Alliance Commercial |
$22.13
|
|
|
DIGOXIN 250 MCG/ML (0.25 MG/ML) INJ SOLN
|
Facility
|
IP
|
$30.36
|
|
|
Service Code
|
HCPCS J1160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Cash Price |
$19.73
|
| Rate for Payer: Health Management Network Commercial |
$25.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.32
|
| Rate for Payer: MDX Hawaii PPO |
$29.45
|
|
|
DILTIAZEM HCL 120 MG PO CAP (24 HR EXTENDED RELEASE)
|
Facility
|
OP
|
$5.34
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$5.29 |
| Rate for Payer: AlohaCare Medicaid |
$2.67
|
| Rate for Payer: AlohaCare Medicare |
$4.81
|
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Devoted Health Medicare |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.07
|
| Rate for Payer: Health Management Network Commercial |
$4.54
|
| Rate for Payer: Humana Medicare |
$4.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.81
|
| Rate for Payer: MDX Hawaii PPO |
$5.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.81
|
| Rate for Payer: University Health Alliance Commercial |
$3.89
|
|
|
DILTIAZEM HCL 120 MG PO CAP (24 HR EXTENDED RELEASE)
|
Facility
|
IP
|
$5.34
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.54 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Cash Price |
$3.47
|
| Rate for Payer: Health Management Network Commercial |
$4.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.81
|
| Rate for Payer: MDX Hawaii PPO |
$5.18
|
|
|
DILTIAZEM HCL 180 MG PO CDCR
|
Facility
|
OP
|
$7.40
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: AlohaCare Medicaid |
$3.70
|
| Rate for Payer: AlohaCare Medicare |
$6.66
|
| Rate for Payer: Cash Price |
$4.81
|
| Rate for Payer: Devoted Health Medicare |
$7.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.03
|
| Rate for Payer: Health Management Network Commercial |
$6.29
|
| Rate for Payer: Humana Medicare |
$6.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.66
|
| Rate for Payer: MDX Hawaii PPO |
$7.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.66
|
| Rate for Payer: University Health Alliance Commercial |
$5.39
|
|
|
DILTIAZEM HCL 180 MG PO CDCR
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$7.18 |
| Rate for Payer: Cash Price |
$4.81
|
| Rate for Payer: Health Management Network Commercial |
$6.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.66
|
| Rate for Payer: MDX Hawaii PPO |
$7.18
|
|
|
DILTIAZEM HCL 240 MG PO CAP (24 HR EXTENDED RELEASE)
|
Facility
|
IP
|
$7.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.22 |
| Max. Negotiated Rate |
$7.10 |
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Health Management Network Commercial |
$6.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.59
|
| Rate for Payer: MDX Hawaii PPO |
$7.10
|
|
|
DILTIAZEM HCL 240 MG PO CAP (24 HR EXTENDED RELEASE)
|
Facility
|
OP
|
$7.32
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$7.25 |
| Rate for Payer: AlohaCare Medicaid |
$3.66
|
| Rate for Payer: AlohaCare Medicare |
$6.59
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Devoted Health Medicare |
$7.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.95
|
| Rate for Payer: Health Management Network Commercial |
$6.22
|
| Rate for Payer: Humana Medicare |
$6.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.59
|
| Rate for Payer: MDX Hawaii PPO |
$7.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.59
|
| Rate for Payer: University Health Alliance Commercial |
$5.34
|
|
|
DILTIAZEM HCL 30 MG PO TABLET
|
Facility
|
IP
|
$2.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$2.81 |
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Health Management Network Commercial |
$2.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.61
|
| Rate for Payer: MDX Hawaii PPO |
$2.81
|
|
|
DILTIAZEM HCL 30 MG PO TABLET
|
Facility
|
OP
|
$2.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: AlohaCare Medicaid |
$1.45
|
| Rate for Payer: AlohaCare Medicare |
$2.61
|
| Rate for Payer: Cash Price |
$1.88
|
| Rate for Payer: Devoted Health Medicare |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.75
|
| Rate for Payer: Health Management Network Commercial |
$2.46
|
| Rate for Payer: Humana Medicare |
$2.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.61
|
| Rate for Payer: MDX Hawaii PPO |
$2.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.61
|
| Rate for Payer: University Health Alliance Commercial |
$2.11
|
|
