Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$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

$71.12

Service Code	NDC 00409663734
Hospital Charge Code	2500757
Hospital Revenue Code	250
Min. Negotiated Rate	$60.45
Max. Negotiated Rate	$68.99
Rate for Payer: Cash Price	$46.23
Rate for Payer: Health Management Network Commercial	$60.45
Rate for Payer: Kaiser Permanente Commercial	$64.01
Rate for Payer: MDX Hawaii PPO	$68.99

sodium bicarbonate 50mEq/50 ml syringe [HHSC]

Facility

$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

$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

$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

$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

$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

$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 5mEq/10 mL syringe [HHSC]

Facility

$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 Chloride 0.45% 1000 ml [HHSC]

Facility

$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

$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 0.9% 1000 ml [HHSC]

Facility

$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

$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

$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

$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

$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	$3.40
Rate for Payer: University Health Alliance Commercial	$2.88

sodium chloride 0.9% 10 ml vial [HHSC]

Facility

$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% 20 ml vial [HHSC]

Facility

$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% 20 ml vial [HHSC]

Facility

$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	$4.71
Rate for Payer: University Health Alliance Commercial	$5.42

Sodium Chloride 0.9% 250 ml bag [HHSC]

Facility

$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

$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

$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

$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

$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

$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

Know your out-of-pocket cost for care.

All Charges