|
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION [7321]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 00264780510
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION [7321]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 63323053075
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION [7321]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 00264780510
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION [7321]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 63323053075
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 63323009301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
NDC 00409114102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 63323009330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
NDC 63323009561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
|
SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION [7322]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
NDC 63323009502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
|
SODIUM CHLORIDE 7 % FOR NEBULIZATION [82134]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00730000000
|
|
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
|
|
|
SODIUM CHLORIDE 7 % FOR NEBULIZATION [82134]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 14123000000
|
|
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
|
|
|
SODIUM CHLORIDE 7 % FOR NEBULIZATION [82134]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00730000000
|
|
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
|
|
|
SODIUM CHLORIDE 7 % FOR NEBULIZATION [82134]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 02160000000
|
|
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
|
|
|
SODIUM CHLORIDE 7 % FOR NEBULIZATION [82134]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 14123000000
|
|
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
|
|
|
SODIUM CHLORIDE 7 % FOR NEBULIZATION [82134]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 02160000000
|
|
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
|
|
|
SODIUM CHLORIDE-ALOE VERA NASAL GEL [15371]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 52547000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [11394]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 19000000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [11394]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 19030000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [11394]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 19000000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [11394]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 19030000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76724]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
NDC 06412000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.15 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.15
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
| Rate for Payer: University Health Alliance Commercial |
$47.38
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76724]
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
NDC 06412000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 00436093616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
SODIUM HYPOCHLORITE 0.25 % SOLUTION [15950]
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 00436093616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$30.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
SODIUM IODIDE-131 (I-131) 3.7 MBQ (100 MICROCI) CAPSULE [209258]
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS A9517
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$50.15 |
| Max. Negotiated Rate |
$57.23 |
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
