|
diltiazem 125mg/25ml vial [HHSC]
|
Facility
|
OP
|
$43.58
|
|
|
Service Code
|
HCPCS J1163
|
| Hospital Charge Code |
2500256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$42.27 |
| Rate for Payer: AlohaCare Medicaid |
$21.79
|
| Rate for Payer: AlohaCare Medicaid |
$29.18
|
| Rate for Payer: AlohaCare Medicaid |
$24.62
|
| Rate for Payer: AlohaCare Medicare |
$24.62
|
| Rate for Payer: AlohaCare Medicare |
$21.79
|
| Rate for Payer: AlohaCare Medicare |
$29.18
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cash Price |
$37.94
|
| Rate for Payer: Cash Price |
$32.01
|
| Rate for Payer: Cash Price |
$28.33
|
| Rate for Payer: Cash Price |
$28.33
|
| Rate for Payer: Cash Price |
$37.94
|
| Rate for Payer: Devoted Health Medicare |
$23.97
|
| Rate for Payer: Devoted Health Medicare |
$32.10
|
| Rate for Payer: Devoted Health Medicare |
$27.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.45
|
| Rate for Payer: Health Management Network Commercial |
$49.61
|
| Rate for Payer: Health Management Network Commercial |
$37.04
|
| Rate for Payer: Health Management Network Commercial |
$41.86
|
| Rate for Payer: Humana Medicare |
$21.79
|
| Rate for Payer: Humana Medicare |
$24.62
|
| Rate for Payer: Humana Medicare |
$29.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.18
|
| Rate for Payer: MDX Hawaii PPO |
$56.62
|
| Rate for Payer: MDX Hawaii PPO |
$47.77
|
| Rate for Payer: MDX Hawaii PPO |
$42.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.18
|
| Rate for Payer: University Health Alliance Commercial |
$31.77
|
| Rate for Payer: University Health Alliance Commercial |
$35.90
|
| Rate for Payer: University Health Alliance Commercial |
$42.55
|
|
|
diltiazem 25 mg/5mL vial [HHSC]
|
Facility
|
IP
|
$15.11
|
|
|
Service Code
|
HCPCS J1163
|
| Hospital Charge Code |
2500257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.84 |
| Max. Negotiated Rate |
$14.66 |
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cash Price |
$14.09
|
| Rate for Payer: Cash Price |
$10.39
|
| Rate for Payer: Health Management Network Commercial |
$12.36
|
| Rate for Payer: Health Management Network Commercial |
$12.84
|
| Rate for Payer: Health Management Network Commercial |
$13.59
|
| Rate for Payer: Health Management Network Commercial |
$18.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$14.10
|
| Rate for Payer: MDX Hawaii PPO |
$15.51
|
| Rate for Payer: MDX Hawaii PPO |
$21.03
|
| Rate for Payer: MDX Hawaii PPO |
$14.66
|
|
|
diltiazem 25 mg/5mL vial [HHSC]
|
Facility
|
OP
|
$15.99
|
|
|
Service Code
|
HCPCS J1163
|
| Hospital Charge Code |
2500257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$15.51 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicaid |
$10.84
|
| Rate for Payer: AlohaCare Medicaid |
$7.55
|
| Rate for Payer: AlohaCare Medicaid |
$7.27
|
| Rate for Payer: AlohaCare Medicare |
$7.27
|
| Rate for Payer: AlohaCare Medicare |
$7.55
|
| Rate for Payer: AlohaCare Medicare |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$10.84
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cash Price |
$10.39
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$9.82
|
| Rate for Payer: Cash Price |
$10.39
|
| Rate for Payer: Cash Price |
$14.09
|
| Rate for Payer: Cash Price |
$9.45
|
| Rate for Payer: Cash Price |
$14.09
|
| Rate for Payer: Devoted Health Medicare |
$8.31
|
| Rate for Payer: Devoted Health Medicare |
$8.79
|
| Rate for Payer: Devoted Health Medicare |
$8.00
|
| Rate for Payer: Devoted Health Medicare |
$11.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.60
|
| Rate for Payer: Health Management Network Commercial |
$18.43
|
| Rate for Payer: Health Management Network Commercial |
$12.84
|
| Rate for Payer: Health Management Network Commercial |
$12.36
|
| Rate for Payer: Health Management Network Commercial |
$13.59
|
| Rate for Payer: Humana Medicare |
$7.55
|
| Rate for Payer: Humana Medicare |
$7.27
|
| Rate for Payer: Humana Medicare |
$8.00
|
| Rate for Payer: Humana Medicare |
$10.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.15
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.27
|
| Rate for Payer: MDX Hawaii PPO |
$21.03
|
| Rate for Payer: MDX Hawaii PPO |
$15.51
|
| Rate for Payer: MDX Hawaii PPO |
$14.66
|
| Rate for Payer: MDX Hawaii PPO |
$14.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.27
|
| Rate for Payer: University Health Alliance Commercial |
$15.80
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
| Rate for Payer: University Health Alliance Commercial |
$10.60
|
| Rate for Payer: University Health Alliance Commercial |
$11.01
|
|
|
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 30 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687056201
|
| 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
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687071701
|
| 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
|
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
|
IP
|
$5.56
|
|
|
Service Code
|
NDC 68682000610
|
| Hospital Charge Code |
2500255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Health Management Network Commercial |
$4.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.00
|
| Rate for Payer: MDX Hawaii PPO |
$5.39
|
|
|
diltiazem 30 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687071701
|
| 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
|
OP
|
$5.56
|
|
|
Service Code
|
NDC 68682000610
|
| Hospital Charge Code |
2500255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: AlohaCare Medicaid |
$2.78
|
| Rate for Payer: AlohaCare Medicare |
$2.78
|
| Rate for Payer: Cash Price |
$3.61
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.28
|
| Rate for Payer: Health Management Network Commercial |
$4.73
|
| Rate for Payer: Humana Medicare |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.78
|
| Rate for Payer: MDX Hawaii PPO |
$5.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.78
|
| Rate for Payer: University Health Alliance Commercial |
$4.05
|
|
|
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 51079074520
|
| 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 60687056201
|
| 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 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 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
|
|
|
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 |
$6.99
|
| Rate for Payer: University Health Alliance Commercial |
$7.10
|
| Rate for Payer: University Health Alliance Commercial |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$2.23
|
|
|
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
|
|
|
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 |
$5.98
|
| Rate for Payer: University Health Alliance Commercial |
$7.66
|
| Rate for Payer: University Health Alliance Commercial |
$4.67
|
| Rate for Payer: University Health Alliance Commercial |
$5.33
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904530660
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2500261
|
|
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
|
|
|
diphenhydrAMINE 25 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904530660
|
| Hospital Charge Code |
2500261
|
|
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
|
|
