|
POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00245531989
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00245531911
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED RELEASE(PART/CRYST) [35943]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68001056700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
POTASSIUM CHLORIDE IV SYRINGE 0.1 MEQ/ML (NEO/PEDS) DRAW FROM BAG [4080139]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
POTASSIUM CHLORIDE IV SYRINGE 0.1 MEQ/ML (NEO/PEDS) DRAW FROM BAG [4080139]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
POTASSIUM CHLORIDE IV SYRINGE 0.2 MEQ/ML (NEO/PEDS,CENTRAL LINE) DRAW FROM BAG [4080138]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
POTASSIUM CHLORIDE IV SYRINGE 0.2 MEQ/ML (NEO/PEDS,CENTRAL LINE) DRAW FROM BAG [4080138]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J3480
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [160215]
|
Facility
|
OP
|
$603.00
|
|
|
Service Code
|
NDC 75834028030
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$307.53 |
| Max. Negotiated Rate |
$584.91 |
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$572.85
|
| Rate for Payer: Health Management Network Commercial |
$512.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$379.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$307.53
|
| Rate for Payer: MDX Hawaii PPO |
$584.91
|
| Rate for Payer: University Health Alliance Commercial |
$439.53
|
|
|
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION [160215]
|
Facility
|
IP
|
$603.00
|
|
|
Service Code
|
NDC 75834028030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$512.55 |
| Max. Negotiated Rate |
$584.91 |
| Rate for Payer: Cash Price |
$361.80
|
| Rate for Payer: Health Management Network Commercial |
$512.55
|
| Rate for Payer: MDX Hawaii PPO |
$584.91
|
|
|
POTASSIUM PHOSPHATE 15 MMOL/250 ML IN NS IVPB (SIMPLE) [4080128]
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
NDC 00004080106
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.40 |
| Max. Negotiated Rate |
$23.28 |
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
|
|
POTASSIUM PHOSPHATE 30 MMOL/500 ML IN NS IVPB (SIMPLE) [4080129]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 00004080107
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
NDC 65219005229
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 80830169102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$183.33 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 80830169101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$160.65 |
| Max. Negotiated Rate |
$183.33 |
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$101.00
|
|
|
Service Code
|
NDC 65219005209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.85 |
| Max. Negotiated Rate |
$97.97 |
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Health Management Network Commercial |
$85.85
|
| Rate for Payer: MDX Hawaii PPO |
$97.97
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
NDC 00517210225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
NDC 00517210201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.70 |
| Max. Negotiated Rate |
$195.94 |
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Health Management Network Commercial |
$171.70
|
| Rate for Payer: MDX Hawaii PPO |
$195.94
|
|
|
POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION [127663]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 00409729501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$53.55
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: MDX Hawaii PPO |
$61.11
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00615000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00615000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00601000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET [70284]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00601000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 00536127180
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
POVIDONE-IODINE 10 % TOPICAL OINTMENT [6455]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 00536127180
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
POVIDONE-IODINE 5 % EYE SOLUTION [19791]
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 00065041130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$72.75 |
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.25
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.25
|
| Rate for Payer: MDX Hawaii PPO |
$72.75
|
| Rate for Payer: University Health Alliance Commercial |
$54.67
|
|
