|
sodium chloride 0.65% spray nasal 44mL [HHSC]
|
Facility
|
IP
|
$11.68
|
|
|
Service Code
|
NDC 00904386575
|
| Hospital Charge Code |
2500781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$11.33 |
| Rate for Payer: Cash Price |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$9.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.51
|
| Rate for Payer: MDX Hawaii PPO |
$11.33
|
|
|
Sodium Chloride 0.9% 1000 ml [HHSC]
|
Facility
|
OP
|
$17.68
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500771
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$17.15 |
| Rate for Payer: AlohaCare Medicaid |
$8.84
|
| Rate for Payer: AlohaCare Medicaid |
$10.12
|
| Rate for Payer: AlohaCare Medicare |
$10.12
|
| Rate for Payer: AlohaCare Medicare |
$8.84
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: Devoted Health Medicare |
$9.72
|
| Rate for Payer: Devoted Health Medicare |
$11.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.23
|
| Rate for Payer: Health Management Network Commercial |
$17.20
|
| Rate for Payer: Health Management Network Commercial |
$15.03
|
| Rate for Payer: Humana Medicare |
$8.84
|
| Rate for Payer: Humana Medicare |
$10.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.12
|
| Rate for Payer: MDX Hawaii PPO |
$17.15
|
| Rate for Payer: MDX Hawaii PPO |
$19.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.61
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.12
|
| Rate for Payer: University Health Alliance Commercial |
$12.89
|
| Rate for Payer: University Health Alliance Commercial |
$14.75
|
|
|
Sodium Chloride 0.9% 1000 ml [HHSC]
|
Facility
|
IP
|
$17.68
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500771
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$17.15 |
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: Health Management Network Commercial |
$15.03
|
| Rate for Payer: Health Management Network Commercial |
$17.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.22
|
| Rate for Payer: MDX Hawaii PPO |
$19.63
|
| Rate for Payer: MDX Hawaii PPO |
$17.15
|
|
|
Sodium Chloride 0.9% 100 ml pgbk [HHSC]
|
Facility
|
IP
|
$18.15
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$17.61 |
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Cash Price |
$21.55
|
| Rate for Payer: Health Management Network Commercial |
$15.43
|
| Rate for Payer: Health Management Network Commercial |
$28.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.84
|
| Rate for Payer: MDX Hawaii PPO |
$32.17
|
| Rate for Payer: MDX Hawaii PPO |
$17.61
|
|
|
Sodium Chloride 0.9% 100 ml pgbk [HHSC]
|
Facility
|
OP
|
$18.15
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500770
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$17.61 |
| Rate for Payer: AlohaCare Medicaid |
$9.07
|
| Rate for Payer: AlohaCare Medicaid |
$16.58
|
| Rate for Payer: AlohaCare Medicare |
$16.58
|
| Rate for Payer: AlohaCare Medicare |
$9.07
|
| Rate for Payer: Cash Price |
$21.55
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: Cash Price |
$21.55
|
| Rate for Payer: Devoted Health Medicare |
$9.98
|
| Rate for Payer: Devoted Health Medicare |
$18.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.50
|
| Rate for Payer: Health Management Network Commercial |
$28.19
|
| Rate for Payer: Health Management Network Commercial |
$15.43
|
| Rate for Payer: Humana Medicare |
$9.07
|
| Rate for Payer: Humana Medicare |
$16.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.58
|
| Rate for Payer: MDX Hawaii PPO |
$17.61
|
| Rate for Payer: MDX Hawaii PPO |
$32.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.58
|
| Rate for Payer: University Health Alliance Commercial |
$13.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.17
|
|
|
sodium chloride 0.9% 10 ml vial [HHSC]
|
Facility
|
IP
|
$5.14
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
2500763
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.37 |
| Max. Negotiated Rate |
$4.99 |
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cash Price |
$3.95
|
| Rate for Payer: Health Management Network Commercial |
$4.37
|
| Rate for Payer: Health Management Network Commercial |
$5.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.46
|
| Rate for Payer: MDX Hawaii PPO |
$5.89
|
| Rate for Payer: MDX Hawaii PPO |
$4.99
|
|
|
sodium chloride 0.9% 10 ml vial [HHSC]
|
Facility
|
OP
|
$6.07
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
2500763
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$5.89 |
| Rate for Payer: AlohaCare Medicaid |
$3.04
|
| Rate for Payer: AlohaCare Medicaid |
$2.57
|
| Rate for Payer: AlohaCare Medicare |
$2.57
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cash Price |
$3.95
|
| Rate for Payer: Devoted Health Medicare |
$3.34
|
| Rate for Payer: Devoted Health Medicare |
$2.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.77
|
| Rate for Payer: Health Management Network Commercial |
$5.16
|
| Rate for Payer: Health Management Network Commercial |
$4.37
|
| Rate for Payer: Humana Medicare |
$2.57
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.57
|
| Rate for Payer: MDX Hawaii PPO |
$4.99
|
| Rate for Payer: MDX Hawaii PPO |
$5.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$4.42
|
| Rate for Payer: University Health Alliance Commercial |
$3.75
|
|
|
sodium chloride 0.9% 20 ml vial [HHSC]
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
2500765
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.83 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: AlohaCare Medicaid |
$4.83
|
| Rate for Payer: AlohaCare Medicaid |
$4.21
|
| Rate for Payer: AlohaCare Medicare |
$4.83
|
| Rate for Payer: AlohaCare Medicare |
$4.21
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Cash Price |
$6.29
|
| Rate for Payer: Devoted Health Medicare |
$4.63
|
| Rate for Payer: Devoted Health Medicare |
$5.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.99
|
| Rate for Payer: Health Management Network Commercial |
$8.22
|
| Rate for Payer: Health Management Network Commercial |
$7.15
|
| Rate for Payer: Humana Medicare |
$4.21
|
| Rate for Payer: Humana Medicare |
$4.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.21
|
| Rate for Payer: MDX Hawaii PPO |
$9.38
|
| Rate for Payer: MDX Hawaii PPO |
$8.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.83
|
| Rate for Payer: University Health Alliance Commercial |
$6.13
|
| Rate for Payer: University Health Alliance Commercial |
$7.05
|
|
|
sodium chloride 0.9% 20 ml vial [HHSC]
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
2500765
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$9.38 |
| Rate for Payer: Cash Price |
$6.29
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Health Management Network Commercial |
$7.15
|
| Rate for Payer: Health Management Network Commercial |
$8.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.70
|
| Rate for Payer: MDX Hawaii PPO |
$9.38
|
| Rate for Payer: MDX Hawaii PPO |
$8.16
|
|
|
Sodium Chloride 0.9% 250 ml bag [HHSC]
|
Facility
|
IP
|
$13.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500772
|
|
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 0.9% 250 ml bag [HHSC]
|
Facility
|
OP
|
$13.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500772
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| 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: Cash Price |
$8.46
|
| Rate for Payer: Devoted Health Medicare |
$7.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| 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 0.9% 3 ml neb soln [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00487930103
|
| Hospital Charge Code |
2500762
|
|
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 chloride 0.9% 3 ml neb soln [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 76204030003
|
| Hospital Charge Code |
2500762
|
|
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 chloride 0.9% 3 ml neb soln [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 76204030003
|
| Hospital Charge Code |
2500762
|
|
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 chloride 0.9% 3 ml neb soln [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00487930133
|
| Hospital Charge Code |
2500762
|
|
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 chloride 0.9% 3 ml neb soln [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00487930133
|
| Hospital Charge Code |
2500762
|
|
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 chloride 0.9% 3 ml neb soln [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00487930103
|
| Hospital Charge Code |
2500762
|
|
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 Chloride 0.9% 500 ml bag [HHSC]
|
Facility
|
OP
|
$13.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500773
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| 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: Cash Price |
$8.46
|
| Rate for Payer: Devoted Health Medicare |
$7.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| 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 0.9% 500 ml bag [HHSC]
|
Facility
|
IP
|
$13.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500773
|
|
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 0.9% 50 mL bag [HHSC]
|
Facility
|
OP
|
$14.81
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500893
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$14.37 |
| Rate for Payer: AlohaCare Medicaid |
$7.41
|
| Rate for Payer: AlohaCare Medicaid |
$4.47
|
| Rate for Payer: AlohaCare Medicaid |
$20.38
|
| Rate for Payer: AlohaCare Medicare |
$20.38
|
| Rate for Payer: AlohaCare Medicare |
$7.41
|
| Rate for Payer: AlohaCare Medicare |
$4.47
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Devoted Health Medicare |
$8.15
|
| Rate for Payer: Devoted Health Medicare |
$4.92
|
| Rate for Payer: Devoted Health Medicare |
$22.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.49
|
| Rate for Payer: Health Management Network Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$12.59
|
| Rate for Payer: Health Management Network Commercial |
$34.65
|
| Rate for Payer: Humana Medicare |
$7.41
|
| Rate for Payer: Humana Medicare |
$20.38
|
| Rate for Payer: Humana Medicare |
$4.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.47
|
| Rate for Payer: MDX Hawaii PPO |
$8.67
|
| Rate for Payer: MDX Hawaii PPO |
$39.54
|
| Rate for Payer: MDX Hawaii PPO |
$14.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.47
|
| Rate for Payer: University Health Alliance Commercial |
$10.80
|
| Rate for Payer: University Health Alliance Commercial |
$29.71
|
| Rate for Payer: University Health Alliance Commercial |
$6.52
|
|
|
Sodium Chloride 0.9% 50 mL bag [HHSC]
|
Facility
|
IP
|
$8.94
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
2500893
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$8.67 |
| Rate for Payer: Cash Price |
$5.81
|
| Rate for Payer: Cash Price |
$26.49
|
| Rate for Payer: Cash Price |
$9.63
|
| Rate for Payer: Health Management Network Commercial |
$12.59
|
| Rate for Payer: Health Management Network Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$34.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.33
|
| Rate for Payer: MDX Hawaii PPO |
$39.54
|
| Rate for Payer: MDX Hawaii PPO |
$14.37
|
| Rate for Payer: MDX Hawaii PPO |
$8.67
|
|
|
sodium chloride 0.9% 50 mL vial [HHSC]
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
2501080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: AlohaCare Medicaid |
$9.36
|
| Rate for Payer: AlohaCare Medicare |
$9.36
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Devoted Health Medicare |
$10.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.78
|
| Rate for Payer: Health Management Network Commercial |
$15.91
|
| Rate for Payer: Humana Medicare |
$9.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.36
|
| Rate for Payer: MDX Hawaii PPO |
$18.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.36
|
| Rate for Payer: University Health Alliance Commercial |
$13.65
|
|
|
sodium chloride 0.9% 50 mL vial [HHSC]
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
HCPCS A4216
|
| Hospital Charge Code |
2501080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.91 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Health Management Network Commercial |
$15.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.85
|
| Rate for Payer: MDX Hawaii PPO |
$18.16
|
|
|
sodium chloride 0.9% Irrig 1000 ml [HHSC]
|
Facility
|
IP
|
$10.40
|
|
|
Service Code
|
NDC 00264220100
|
| Hospital Charge Code |
2500766
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$10.09 |
| Rate for Payer: Cash Price |
$6.76
|
| Rate for Payer: Health Management Network Commercial |
$8.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.36
|
| Rate for Payer: MDX Hawaii PPO |
$10.09
|
|
|
sodium chloride 0.9% Irrig 1000 ml [HHSC]
|
Facility
|
OP
|
$10.40
|
|
|
Service Code
|
NDC 00264220100
|
| Hospital Charge Code |
2500766
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$10.09 |
| Rate for Payer: AlohaCare Medicaid |
$5.20
|
| Rate for Payer: AlohaCare Medicare |
$5.20
|
| Rate for Payer: Cash Price |
$6.76
|
| Rate for Payer: Devoted Health Medicare |
$5.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.88
|
| Rate for Payer: Health Management Network Commercial |
$8.84
|
| Rate for Payer: Humana Medicare |
$5.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.20
|
| Rate for Payer: MDX Hawaii PPO |
$10.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.20
|
| Rate for Payer: University Health Alliance Commercial |
$7.58
|
|
