|
sodium chloride 3% 4 mL neb soln [HHSC]
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 76204002260
|
| Hospital Charge Code |
2500779
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Cash Price |
$3.04
|
| Rate for Payer: Health Management Network Commercial |
$3.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.20
|
| Rate for Payer: MDX Hawaii PPO |
$4.53
|
|
|
sodium chloride 3% 4 mL neb soln [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00487900360
|
| Hospital Charge Code |
2500779
|
|
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 3% 4 mL neb soln [HHSC]
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 00487900330
|
| Hospital Charge Code |
2500779
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.78 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Health Management Network Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.00
|
| Rate for Payer: MDX Hawaii PPO |
$4.32
|
|
|
sodium chloride 3% 4 mL neb soln [HHSC]
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 00487900330
|
| Hospital Charge Code |
2500779
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: AlohaCare Medicaid |
$2.23
|
| Rate for Payer: AlohaCare Medicare |
$2.23
|
| Rate for Payer: Cash Price |
$2.89
|
| Rate for Payer: Devoted Health Medicare |
$2.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.23
|
| Rate for Payer: Health Management Network Commercial |
$3.78
|
| Rate for Payer: Humana Medicare |
$2.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.23
|
| Rate for Payer: MDX Hawaii PPO |
$4.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.23
|
| Rate for Payer: University Health Alliance Commercial |
$3.24
|
|
|
sodium chloride 3% 4 mL neb soln [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00487900360
|
| Hospital Charge Code |
2500779
|
|
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 3% 500 ml [HHSC]
|
Facility
|
IP
|
$26.69
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
2500780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.69 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$14.13
|
| Rate for Payer: Cash Price |
$25.77
|
| Rate for Payer: Health Management Network Commercial |
$33.70
|
| Rate for Payer: Health Management Network Commercial |
$18.48
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$21.09
|
| Rate for Payer: MDX Hawaii PPO |
$38.46
|
|
|
sodium chloride 3% 500 ml [HHSC]
|
Facility
|
OP
|
$21.74
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
2500780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.87 |
| Max. Negotiated Rate |
$21.09 |
| Rate for Payer: AlohaCare Medicaid |
$10.87
|
| Rate for Payer: AlohaCare Medicaid |
$13.35
|
| Rate for Payer: AlohaCare Medicaid |
$19.82
|
| Rate for Payer: AlohaCare Medicare |
$13.35
|
| Rate for Payer: AlohaCare Medicare |
$10.87
|
| Rate for Payer: AlohaCare Medicare |
$19.82
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$14.13
|
| Rate for Payer: Cash Price |
$25.77
|
| Rate for Payer: Devoted Health Medicare |
$11.96
|
| Rate for Payer: Devoted Health Medicare |
$21.81
|
| Rate for Payer: Devoted Health Medicare |
$14.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.82
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.67
|
| Rate for Payer: Health Management Network Commercial |
$22.69
|
| Rate for Payer: Health Management Network Commercial |
$18.48
|
| Rate for Payer: Health Management Network Commercial |
$33.70
|
| Rate for Payer: Humana Medicare |
$19.82
|
| Rate for Payer: Humana Medicare |
$10.87
|
| Rate for Payer: Humana Medicare |
$13.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.82
|
| Rate for Payer: MDX Hawaii PPO |
$21.09
|
| Rate for Payer: MDX Hawaii PPO |
$38.46
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.35
|
| Rate for Payer: University Health Alliance Commercial |
$28.90
|
| Rate for Payer: University Health Alliance Commercial |
$15.85
|
| Rate for Payer: University Health Alliance Commercial |
$19.45
|
|
|
sodium chloride 5% ophth drop [HHSC]
|
Facility
|
IP
|
$7.11
|
|
|
Service Code
|
NDC 24208027715
|
| Hospital Charge Code |
2500782
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$6.90 |
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Health Management Network Commercial |
$6.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.40
|
| Rate for Payer: MDX Hawaii PPO |
$6.90
|
|
|
sodium chloride 5% ophth drop [HHSC]
|
Facility
|
OP
|
$7.11
|
|
|
Service Code
|
NDC 24208027715
|
| Hospital Charge Code |
2500782
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$6.90 |
| Rate for Payer: AlohaCare Medicaid |
$3.56
|
| Rate for Payer: AlohaCare Medicare |
$3.56
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Devoted Health Medicare |
$3.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.75
|
| Rate for Payer: Health Management Network Commercial |
$6.04
|
| Rate for Payer: Humana Medicare |
$3.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.56
|
| Rate for Payer: MDX Hawaii PPO |
$6.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.56
|
| Rate for Payer: University Health Alliance Commercial |
$5.18
|
|
|
sodium chloride 5% ophth drop [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00536125494
|
| Hospital Charge Code |
2500782
|
|
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 5% ophth drop [HHSC]
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
NDC 17478062312
|
| Hospital Charge Code |
2500782
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Health Management Network Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.04
|
| Rate for Payer: MDX Hawaii PPO |
$4.36
|
|
|
sodium chloride 5% ophth drop [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00536125494
|
| Hospital Charge Code |
2500782
|
|
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 5% ophth drop [HHSC]
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
NDC 17478062312
|
| Hospital Charge Code |
2500782
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: AlohaCare Medicaid |
$2.25
|
| Rate for Payer: AlohaCare Medicare |
$2.25
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Devoted Health Medicare |
$2.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.27
|
| Rate for Payer: Health Management Network Commercial |
$3.82
|
| Rate for Payer: Humana Medicare |
$2.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.69
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.25
|
| Rate for Payer: University Health Alliance Commercial |
$3.27
|
|
|
Sodium iSTAT
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
HCPCS 84295 QW
|
| Hospital Charge Code |
8293268
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$213.40 |
| Rate for Payer: AlohaCare Medicaid |
$110.00
|
| Rate for Payer: AlohaCare Medicare |
$110.00
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Devoted Health Medicare |
$121.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.81
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Humana Medicare |
$110.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$112.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.00
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.00
|
| Rate for Payer: University Health Alliance Commercial |
$12.43
|
|
|
Sodium iSTAT
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
HCPCS 84295 QW
|
| Hospital Charge Code |
8293268
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$187.00 |
| Max. Negotiated Rate |
$213.40 |
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
|
|
Sodium Level FSI
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
HCPCS 84295
|
| Hospital Charge Code |
8128150
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: AlohaCare Medicaid |
$112.50
|
| Rate for Payer: AlohaCare Medicare |
$112.50
|
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Devoted Health Medicare |
$123.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.65
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$6.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$112.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.81
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Humana Medicare |
$112.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$114.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$112.50
|
| Rate for Payer: MDX Hawaii PPO |
$218.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$112.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$112.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$112.50
|
| Rate for Payer: University Health Alliance Commercial |
$12.43
|
|
|
Sodium Level FSI
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
HCPCS 84295
|
| Hospital Charge Code |
8128150
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$191.25 |
| Max. Negotiated Rate |
$218.25 |
| Rate for Payer: Cash Price |
$146.25
|
| Rate for Payer: Health Management Network Commercial |
$191.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$202.50
|
| Rate for Payer: MDX Hawaii PPO |
$218.25
|
|
|
sodium nitrite 300 mg/10 mL vial [HHSC]
|
Facility
|
IP
|
$317.93
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2501076
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$270.24 |
| Max. Negotiated Rate |
$308.39 |
| Rate for Payer: Cash Price |
$206.65
|
| Rate for Payer: Health Management Network Commercial |
$270.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$286.14
|
| Rate for Payer: MDX Hawaii PPO |
$308.39
|
|
|
sodium nitrite 300 mg/10 mL vial [HHSC]
|
Facility
|
OP
|
$317.93
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2501076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$158.97 |
| Max. Negotiated Rate |
$308.39 |
| Rate for Payer: AlohaCare Medicaid |
$158.97
|
| Rate for Payer: AlohaCare Medicare |
$158.97
|
| Rate for Payer: Cash Price |
$206.65
|
| Rate for Payer: Devoted Health Medicare |
$174.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$158.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$302.03
|
| Rate for Payer: Health Management Network Commercial |
$270.24
|
| Rate for Payer: Humana Medicare |
$158.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$286.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$162.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$158.97
|
| Rate for Payer: MDX Hawaii PPO |
$308.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$158.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$190.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$158.97
|
| Rate for Payer: University Health Alliance Commercial |
$231.74
|
|
|
sodium phosphates enema 133 mL [HHSC]
|
Facility
|
IP
|
$6.45
|
|
|
Service Code
|
NDC 00132020140
|
| Hospital Charge Code |
2500758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.48 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Health Management Network Commercial |
$5.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.80
|
| Rate for Payer: MDX Hawaii PPO |
$6.26
|
|
|
sodium phosphates enema 133 mL [HHSC]
|
Facility
|
OP
|
$5.73
|
|
|
Service Code
|
NDC 00536741551
|
| Hospital Charge Code |
2500758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: AlohaCare Medicaid |
$2.87
|
| Rate for Payer: AlohaCare Medicare |
$2.87
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Devoted Health Medicare |
$3.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.44
|
| Rate for Payer: Health Management Network Commercial |
$4.87
|
| Rate for Payer: Humana Medicare |
$2.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.87
|
| Rate for Payer: MDX Hawaii PPO |
$5.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.87
|
| Rate for Payer: University Health Alliance Commercial |
$4.18
|
|
|
sodium phosphates enema 133 mL [HHSC]
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 00904632078
|
| Hospital Charge Code |
2500758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.03 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: Cash Price |
$6.14
|
| Rate for Payer: Health Management Network Commercial |
$8.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.51
|
| Rate for Payer: MDX Hawaii PPO |
$9.17
|
|
|
sodium phosphates enema 133 mL [HHSC]
|
Facility
|
IP
|
$5.73
|
|
|
Service Code
|
NDC 00536741551
|
| Hospital Charge Code |
2500758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Health Management Network Commercial |
$4.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.16
|
| Rate for Payer: MDX Hawaii PPO |
$5.56
|
|
|
sodium phosphates enema 133 mL [HHSC]
|
Facility
|
OP
|
$6.45
|
|
|
Service Code
|
NDC 00132020140
|
| Hospital Charge Code |
2500758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$6.26 |
| Rate for Payer: AlohaCare Medicaid |
$3.23
|
| Rate for Payer: AlohaCare Medicare |
$3.23
|
| Rate for Payer: Cash Price |
$4.19
|
| Rate for Payer: Devoted Health Medicare |
$3.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.13
|
| Rate for Payer: Health Management Network Commercial |
$5.48
|
| Rate for Payer: Humana Medicare |
$3.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.23
|
| Rate for Payer: MDX Hawaii PPO |
$6.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.23
|
| Rate for Payer: University Health Alliance Commercial |
$4.70
|
|
|
sodium phosphates enema 133 mL [HHSC]
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 00904632078
|
| Hospital Charge Code |
2500758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$9.17 |
| Rate for Payer: AlohaCare Medicaid |
$4.72
|
| Rate for Payer: AlohaCare Medicare |
$4.72
|
| Rate for Payer: Cash Price |
$6.14
|
| Rate for Payer: Devoted Health Medicare |
$5.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.98
|
| Rate for Payer: Health Management Network Commercial |
$8.03
|
| Rate for Payer: Humana Medicare |
$4.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.72
|
| Rate for Payer: MDX Hawaii PPO |
$9.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.72
|
| Rate for Payer: University Health Alliance Commercial |
$6.89
|
|
