|
sodium bicarbonate 50mEq/50 ml syringe [HHSC]
|
Facility
|
OP
|
$64.77
|
|
|
Service Code
|
NDC 00409662502
|
| Hospital Charge Code |
2500757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.38 |
| Max. Negotiated Rate |
$62.83 |
| Rate for Payer: AlohaCare Medicaid |
$32.38
|
| Rate for Payer: AlohaCare Medicare |
$32.38
|
| Rate for Payer: Cash Price |
$42.10
|
| Rate for Payer: Devoted Health Medicare |
$35.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$61.53
|
| Rate for Payer: Health Management Network Commercial |
$55.05
|
| Rate for Payer: Humana Medicare |
$32.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$58.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.38
|
| Rate for Payer: MDX Hawaii PPO |
$62.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$38.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.38
|
| Rate for Payer: University Health Alliance Commercial |
$47.21
|
|
|
sodium bicarbonate 50mEq/50 ml syringe [HHSC]
|
Facility
|
IP
|
$67.49
|
|
|
Service Code
|
NDC 00409662514
|
| Hospital Charge Code |
2500757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$57.37 |
| Max. Negotiated Rate |
$65.47 |
| Rate for Payer: Cash Price |
$43.87
|
| Rate for Payer: Health Management Network Commercial |
$57.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.74
|
| Rate for Payer: MDX Hawaii PPO |
$65.47
|
|
|
sodium bicarbonate 50mEq/50 ml syringe [HHSC]
|
Facility
|
OP
|
$71.12
|
|
|
Service Code
|
NDC 00409663734
|
| Hospital Charge Code |
2500757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.56 |
| Max. Negotiated Rate |
$68.99 |
| Rate for Payer: AlohaCare Medicaid |
$35.56
|
| Rate for Payer: AlohaCare Medicare |
$35.56
|
| Rate for Payer: Cash Price |
$46.23
|
| Rate for Payer: Devoted Health Medicare |
$39.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.56
|
| Rate for Payer: Health Management Network Commercial |
$60.45
|
| Rate for Payer: Humana Medicare |
$35.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.56
|
| Rate for Payer: MDX Hawaii PPO |
$68.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.56
|
| Rate for Payer: University Health Alliance Commercial |
$51.84
|
|
|
sodium bicarbonate 50mEq/50 ml syringe [HHSC]
|
Facility
|
IP
|
$60.82
|
|
|
Service Code
|
NDC 51754500105
|
| Hospital Charge Code |
2500757
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.70 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Cash Price |
$39.53
|
| Rate for Payer: Health Management Network Commercial |
$51.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.74
|
| Rate for Payer: MDX Hawaii PPO |
$59.00
|
|
|
sodium bicarbonate 5mEq/10 mL syringe [HHSC]
|
Facility
|
OP
|
$70.12
|
|
|
Service Code
|
NDC 00409553434
|
| Hospital Charge Code |
2500754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.06 |
| Max. Negotiated Rate |
$68.02 |
| Rate for Payer: AlohaCare Medicaid |
$35.06
|
| Rate for Payer: AlohaCare Medicare |
$35.06
|
| Rate for Payer: Cash Price |
$45.58
|
| Rate for Payer: Devoted Health Medicare |
$38.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.06
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.61
|
| Rate for Payer: Health Management Network Commercial |
$59.60
|
| Rate for Payer: Humana Medicare |
$35.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.06
|
| Rate for Payer: MDX Hawaii PPO |
$68.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$42.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.06
|
| Rate for Payer: University Health Alliance Commercial |
$51.11
|
|
|
sodium bicarbonate 5mEq/10 mL syringe [HHSC]
|
Facility
|
IP
|
$75.09
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
2500754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$63.83 |
| Max. Negotiated Rate |
$72.84 |
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Health Management Network Commercial |
$63.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.58
|
| Rate for Payer: MDX Hawaii PPO |
$72.84
|
|
|
sodium bicarbonate 5mEq/10 mL syringe [HHSC]
|
Facility
|
OP
|
$75.09
|
|
|
Service Code
|
NDC 00409553414
|
| Hospital Charge Code |
2500754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.55 |
| Max. Negotiated Rate |
$72.84 |
| Rate for Payer: AlohaCare Medicaid |
$37.55
|
| Rate for Payer: AlohaCare Medicare |
$37.55
|
| Rate for Payer: Cash Price |
$48.81
|
| Rate for Payer: Devoted Health Medicare |
$41.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$71.34
|
| Rate for Payer: Health Management Network Commercial |
$63.83
|
| Rate for Payer: Humana Medicare |
$37.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.55
|
| Rate for Payer: MDX Hawaii PPO |
$72.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.55
|
| Rate for Payer: University Health Alliance Commercial |
$54.73
|
|
|
sodium bicarbonate 5mEq/10 mL syringe [HHSC]
|
Facility
|
IP
|
$70.12
|
|
|
Service Code
|
NDC 00409553434
|
| Hospital Charge Code |
2500754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.60 |
| Max. Negotiated Rate |
$68.02 |
| Rate for Payer: Cash Price |
$45.58
|
| Rate for Payer: Health Management Network Commercial |
$59.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.11
|
| Rate for Payer: MDX Hawaii PPO |
$68.02
|
|
|
sodium bicarbonate 5mEq/10 mL syringe [HHSC]
|
Facility
|
OP
|
$52.93
|
|
|
Service Code
|
NDC 51754501204
|
| Hospital Charge Code |
2500754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$51.34 |
| Rate for Payer: AlohaCare Medicaid |
$26.46
|
| Rate for Payer: AlohaCare Medicare |
$26.46
|
| Rate for Payer: Cash Price |
$34.40
|
| Rate for Payer: Devoted Health Medicare |
$29.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.46
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.28
|
| Rate for Payer: Health Management Network Commercial |
$44.99
|
| Rate for Payer: Humana Medicare |
$26.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.46
|
| Rate for Payer: MDX Hawaii PPO |
$51.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.46
|
| Rate for Payer: University Health Alliance Commercial |
$38.58
|
|
|
sodium bicarbonate 5mEq/10 mL syringe [HHSC]
|
Facility
|
IP
|
$52.93
|
|
|
Service Code
|
NDC 51754501204
|
| Hospital Charge Code |
2500754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.99 |
| Max. Negotiated Rate |
$51.34 |
| Rate for Payer: Cash Price |
$34.40
|
| Rate for Payer: Health Management Network Commercial |
$44.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.64
|
| Rate for Payer: MDX Hawaii PPO |
$51.34
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 66553000801
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 77333083110
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 77333083110
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 77333082710
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904726161
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 66553000801
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
sodium bicarbonate 650 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 77333082710
|
| Hospital Charge Code |
2500756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
Sodium Chl 0.45%-KCL 20 mEq 1000ml [HHSC]
|
Facility
|
OP
|
$43.82
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
2500761
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$42.51 |
| Rate for Payer: AlohaCare Medicaid |
$21.91
|
| Rate for Payer: AlohaCare Medicare |
$21.91
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Devoted Health Medicare |
$24.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.91
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.63
|
| Rate for Payer: Health Management Network Commercial |
$37.25
|
| Rate for Payer: Humana Medicare |
$21.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.91
|
| Rate for Payer: MDX Hawaii PPO |
$42.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.91
|
| Rate for Payer: University Health Alliance Commercial |
$31.94
|
|
|
Sodium Chl 0.45%-KCL 20 mEq 1000ml [HHSC]
|
Facility
|
IP
|
$43.82
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
2500761
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.25 |
| Max. Negotiated Rate |
$42.51 |
| Rate for Payer: Cash Price |
$28.48
|
| Rate for Payer: Health Management Network Commercial |
$37.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.44
|
| Rate for Payer: MDX Hawaii PPO |
$42.51
|
|
|
Sodium Chloride 0.45% 1000 ml [HHSC]
|
Facility
|
IP
|
$13.01
|
|
|
Service Code
|
NDC 00264780200
|
| Hospital Charge Code |
2500760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Health Management Network Commercial |
$11.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.71
|
| Rate for Payer: MDX Hawaii PPO |
$12.62
|
|
|
Sodium Chloride 0.45% 1000 ml [HHSC]
|
Facility
|
OP
|
$13.01
|
|
|
Service Code
|
NDC 00264780200
|
| Hospital Charge Code |
2500760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.50 |
| Max. Negotiated Rate |
$12.62 |
| Rate for Payer: AlohaCare Medicaid |
$6.50
|
| Rate for Payer: AlohaCare Medicare |
$6.50
|
| Rate for Payer: Cash Price |
$8.46
|
| Rate for Payer: Devoted Health Medicare |
$7.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.36
|
| Rate for Payer: Health Management Network Commercial |
$11.06
|
| Rate for Payer: Humana Medicare |
$6.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.50
|
| Rate for Payer: MDX Hawaii PPO |
$12.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.50
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
sodium chloride 0.65% spray nasal 44mL [HHSC]
|
Facility
|
OP
|
$7.23
|
|
|
Service Code
|
NDC 24385032558
|
| Hospital Charge Code |
2500781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$7.01 |
| Rate for Payer: AlohaCare Medicaid |
$3.62
|
| Rate for Payer: AlohaCare Medicare |
$3.62
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Devoted Health Medicare |
$3.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.87
|
| Rate for Payer: Health Management Network Commercial |
$6.15
|
| Rate for Payer: Humana Medicare |
$3.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.62
|
| Rate for Payer: MDX Hawaii PPO |
$7.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.62
|
| Rate for Payer: University Health Alliance Commercial |
$5.27
|
|
|
sodium chloride 0.65% spray nasal 44mL [HHSC]
|
Facility
|
IP
|
$7.23
|
|
|
Service Code
|
NDC 24385032558
|
| Hospital Charge Code |
2500781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$7.01 |
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Health Management Network Commercial |
$6.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.51
|
| Rate for Payer: MDX Hawaii PPO |
$7.01
|
|
|
sodium chloride 0.65% spray nasal 44mL [HHSC]
|
Facility
|
OP
|
$11.68
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
2500781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: AlohaCare Medicaid |
$5.84
|
| Rate for Payer: AlohaCare Medicare |
$5.84
|
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Devoted Health Medicare |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.10
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Humana Medicare |
$5.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.84
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.84
|
| Rate for Payer: University Health Alliance Commercial |
$8.51
|
|
