|
SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION [131263]
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
NDC 00006542312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$209.10 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
NDC 24208031705
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.66 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
|
|
SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) EYE DROPS [70392]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
NDC 24208031705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
NDC 24208067004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.14 |
| Max. Negotiated Rate |
$207.58 |
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$203.30
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$109.14
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
| Rate for Payer: University Health Alliance Commercial |
$155.98
|
|
|
SULFACETAMIDE SODIUM 10 % EYE DROPS [7359]
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
NDC 24208067004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$181.90 |
| Max. Negotiated Rate |
$207.58 |
| Rate for Payer: Cash Price |
$128.40
|
| Rate for Payer: Health Management Network Commercial |
$181.90
|
| Rate for Payer: MDX Hawaii PPO |
$207.58
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
OP
|
$319.00
|
|
|
Service Code
|
NDC 65862049647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.69 |
| Max. Negotiated Rate |
$309.43 |
| Rate for Payer: Cash Price |
$191.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$303.05
|
| Rate for Payer: Health Management Network Commercial |
$271.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$200.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$162.69
|
| Rate for Payer: MDX Hawaii PPO |
$309.43
|
| Rate for Payer: University Health Alliance Commercial |
$232.52
|
|
|
SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION [22560]
|
Facility
|
IP
|
$319.00
|
|
|
Service Code
|
NDC 65862049647
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$271.15 |
| Max. Negotiated Rate |
$309.43 |
| Rate for Payer: Cash Price |
$191.40
|
| Rate for Payer: Health Management Network Commercial |
$271.15
|
| Rate for Payer: MDX Hawaii PPO |
$309.43
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
NDC 00703951403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$51.41 |
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 70069036201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$52.38 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION [7556]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
NDC 70069036210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$52.38 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65862041901
|
|
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
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687060365
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687060365
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687060311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687060311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET [7557]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 65862041901
|
|
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
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687061401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904272561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687061411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687061401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687061411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET [11599]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904272561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160 MG TABLETS (BACTRIM DS) (TAKE HOME) [4080340]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080128
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160 MG TABLETS (BACTRIM DS) (TAKE HOME) [4080340]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080128
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
SULFAMETH/TMP 200-40 MG/5 ML SUSPENSION (BACTRIM) (120 ML) (TAKE HOME) [4080398]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080186
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
