|
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: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
|
|
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 |
$5.89 |
| Max. Negotiated Rate |
$18.43 |
| Rate for Payer: AlohaCare Medicaid |
$9.50
|
| Rate for Payer: AlohaCare Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Devoted Health Medicare |
$6.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.05
|
| Rate for Payer: Health Management Network Commercial |
$16.15
|
| Rate for Payer: Humana Medicare |
$5.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$18.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.89
|
| Rate for Payer: University Health Alliance Commercial |
$13.85
|
|
|
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: Kaiser Permanente Commercial |
$58.50
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
|
|
SODIUM HYPOCHLORITE 0.125 % SOLUTION [76724]
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
NDC 06412000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.15 |
| Max. Negotiated Rate |
$63.05 |
| Rate for Payer: AlohaCare Medicaid |
$32.50
|
| Rate for Payer: AlohaCare Medicare |
$20.15
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Devoted Health Medicare |
$22.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.75
|
| Rate for Payer: Health Management Network Commercial |
$55.25
|
| Rate for Payer: Humana Medicare |
$20.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.15
|
| Rate for Payer: MDX Hawaii PPO |
$63.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.15
|
| Rate for Payer: University Health Alliance Commercial |
$47.38
|
|
|
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: Kaiser Permanente Commercial |
$44.10
|
| 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 |
$15.19 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$15.19
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Devoted Health Medicare |
$16.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$15.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.19
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.19
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
SODIUM IODIDE-131 (I-131) 3.7 MBQ (100 MICROCI) CAPSULE [209258]
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS A9517
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$117.25 |
| Rate for Payer: AlohaCare Medicaid |
$29.50
|
| Rate for Payer: AlohaCare Medicare |
$18.29
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Devoted Health Medicare |
$20.06
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$30.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$56.05
|
| Rate for Payer: Health Management Network Commercial |
$50.15
|
| Rate for Payer: Humana Medicare |
$18.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.29
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$117.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.29
|
| Rate for Payer: University Health Alliance Commercial |
$43.01
|
|
|
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: Kaiser Permanente Commercial |
$53.10
|
| Rate for Payer: MDX Hawaii PPO |
$57.23
|
|
|
SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION [18908]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 72485010501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
NDC 63323088101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$98.60 |
| Max. Negotiated Rate |
$112.52 |
| Rate for Payer: Cash Price |
$69.60
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Health Management Network Commercial |
$98.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$104.40
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: MDX Hawaii PPO |
$112.52
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
NDC 00409739182
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.65 |
| Max. Negotiated Rate |
$163.93 |
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Health Management Network Commercial |
$143.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.10
|
| Rate for Payer: MDX Hawaii PPO |
$163.93
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
NDC 63323088401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.70 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
NDC 00409739172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.65 |
| Max. Negotiated Rate |
$163.93 |
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Health Management Network Commercial |
$143.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.10
|
| Rate for Payer: MDX Hawaii PPO |
$163.93
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]
|
Facility
|
IP
|
$174.00
|
|
|
Service Code
|
NDC 63323088116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$147.90 |
| Max. Negotiated Rate |
$168.78 |
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Health Management Network Commercial |
$147.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$156.60
|
| Rate for Payer: MDX Hawaii PPO |
$168.78
|
|
|
SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION [137040]
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
NDC 63323088406
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.70 |
| Max. Negotiated Rate |
$79.54 |
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Health Management Network Commercial |
$69.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$73.80
|
| Rate for Payer: MDX Hawaii PPO |
$79.54
|
|
|
SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA [2805]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00132020140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [3128]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 00132020220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA [3128]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 00132020220
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
SODIUM POLYSTYRENE SULFONATE POWDER [7356]
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
NDC 11534016616
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Health Management Network Commercial |
$47.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: MDX Hawaii PPO |
$54.32
|
|
|
SODIUM POLYSTYRENE SULFONATE POWDER [7356]
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
NDC 11534016616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: AlohaCare Medicaid |
$28.00
|
| Rate for Payer: AlohaCare Medicare |
$17.36
|
| Rate for Payer: Cash Price |
$33.60
|
| Rate for Payer: Devoted Health Medicare |
$19.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.20
|
| Rate for Payer: Health Management Network Commercial |
$47.60
|
| Rate for Payer: Humana Medicare |
$17.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.36
|
| Rate for Payer: MDX Hawaii PPO |
$54.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.36
|
| Rate for Payer: University Health Alliance Commercial |
$40.82
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
NDC 24201020101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$196.35 |
| Max. Negotiated Rate |
$224.07 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Health Management Network Commercial |
$196.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$207.90
|
| Rate for Payer: MDX Hawaii PPO |
$224.07
|
|
|
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION [41793]
|
Facility
|
IP
|
$231.00
|
|
|
Service Code
|
NDC 24201020105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$196.35 |
| Max. Negotiated Rate |
$224.07 |
| Rate for Payer: Cash Price |
$138.60
|
| Rate for Payer: Health Management Network Commercial |
$196.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$207.90
|
| Rate for Payer: MDX Hawaii PPO |
$224.07
|
|
|
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INJECTION SOLUTION [181343]
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
NDC 60267070550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$345.10 |
| Max. Negotiated Rate |
$393.82 |
| Rate for Payer: Cash Price |
$243.60
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Health Management Network Commercial |
$345.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$365.40
|
| Rate for Payer: MDX Hawaii PPO |
$393.82
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [162642]
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
NDC 00310111001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.95 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
|
|
SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET [162642]
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
NDC 00310111001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.97 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: AlohaCare Medicaid |
$43.50
|
| Rate for Payer: AlohaCare Medicare |
$26.97
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Devoted Health Medicare |
$29.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.65
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Humana Medicare |
$26.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.97
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.97
|
| Rate for Payer: University Health Alliance Commercial |
$63.41
|
|
