|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00121176230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 00536001583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 00536001583
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP [9014]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00121176230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60687042211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 50268006915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.03 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$4.03
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Devoted Health Medicare |
$4.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Humana Medicare |
$4.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.03
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.03
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 60687042201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 50268006915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 60687042211
|
|
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: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
AMANTADINE HCL 100 MG CAPSULE [364]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 60687042201
|
|
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: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [180668]
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
NDC 00121064616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.40 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
|
|
AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION [180668]
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
NDC 00121064616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$139.68 |
| Rate for Payer: AlohaCare Medicaid |
$72.00
|
| Rate for Payer: AlohaCare Medicare |
$44.64
|
| Rate for Payer: Cash Price |
$86.40
|
| Rate for Payer: Devoted Health Medicare |
$48.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$136.80
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Humana Medicare |
$44.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$129.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.64
|
| Rate for Payer: MDX Hawaii PPO |
$139.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.64
|
| Rate for Payer: University Health Alliance Commercial |
$104.96
|
|
|
AMBIENT HIPVAC 50 IFS
|
Facility
|
IP
|
$1,500.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
|
|
AMBIENT HIPVAC 50 IFS
|
Facility
|
OP
|
$1,500.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$465.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: AlohaCare Medicaid |
$750.00
|
| Rate for Payer: AlohaCare Medicare |
$465.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Devoted Health Medicare |
$510.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$465.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,425.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Humana Medicare |
$465.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$765.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$465.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$465.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$465.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$465.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,093.35
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS J0278
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicaid |
$20.50
|
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$12.71
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: AlohaCare Medicare |
$9.92
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Devoted Health Medicare |
$13.94
|
| Rate for Payer: Devoted Health Medicare |
$10.88
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.62
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Health Management Network Commercial |
$34.85
|
| Rate for Payer: Humana Medicare |
$9.92
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Humana Medicare |
$12.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.71
|
| Rate for Payer: MDX Hawaii PPO |
$39.77
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.92
|
| Rate for Payer: University Health Alliance Commercial |
$29.88
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
AMIKACIN 500 MG/2 ML INJECTION SOLUTION [108131]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS J0278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Health Management Network Commercial |
$34.85
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: MDX Hawaii PPO |
$39.77
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00574029201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
AMILORIDE 5 MG TABLET [391]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00574029201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
NDC 00338114403
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$309.40 |
| Max. Negotiated Rate |
$353.08 |
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Health Management Network Commercial |
$154.70
|
| Rate for Payer: Health Management Network Commercial |
$309.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$163.80
|
| Rate for Payer: MDX Hawaii PPO |
$353.08
|
| Rate for Payer: MDX Hawaii PPO |
$176.54
|
|
|
AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
NDC 00338702201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$154.70 |
| Max. Negotiated Rate |
$176.54 |
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Health Management Network Commercial |
$154.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$163.80
|
| Rate for Payer: MDX Hawaii PPO |
$176.54
|
|
|
AMINO ACID 4.25 % NO.1-DEXTROSE 5 %-ELECTROLYTES NO.39 IV SOLUTION [23162]
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
NDC 00338702206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$154.70 |
| Max. Negotiated Rate |
$176.54 |
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Health Management Network Commercial |
$154.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$163.80
|
| Rate for Payer: MDX Hawaii PPO |
$176.54
|
|
|
AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION [25749]
|
Facility
|
IP
|
$161.00
|
|
|
Service Code
|
NDC 00338113303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.85 |
| Max. Negotiated Rate |
$156.17 |
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Health Management Network Commercial |
$136.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.90
|
| Rate for Payer: MDX Hawaii PPO |
$156.17
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 20 %-ELECTROLYTES NO.23 IV SOLUTION [23214]
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
NDC 00338112504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$309.40 |
| Max. Negotiated Rate |
$353.08 |
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$309.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.60
|
| Rate for Payer: MDX Hawaii PPO |
$353.08
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 20 %-ELECTROLYTES NO.23 IV SOLUTION [23214]
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
NDC 00338703604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$309.40 |
| Max. Negotiated Rate |
$353.08 |
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Health Management Network Commercial |
$309.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$327.60
|
| Rate for Payer: MDX Hawaii PPO |
$353.08
|
|
|
AMINO ACID 5 % NO.6-DEXTROSE 20 %-ELECTROLYTES NO.23 IV SOLUTION [23214]
|
Facility
|
IP
|
$378.00
|
|
|
Service Code
|
NDC 00338114803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$321.30 |
| Max. Negotiated Rate |
$366.66 |
| Rate for Payer: Cash Price |
$226.80
|
| Rate for Payer: Cash Price |
$113.40
|
| Rate for Payer: Health Management Network Commercial |
$160.65
|
| Rate for Payer: Health Management Network Commercial |
$321.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$170.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$340.20
|
| Rate for Payer: MDX Hawaii PPO |
$366.66
|
| Rate for Payer: MDX Hawaii PPO |
$183.33
|
|
