|
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%- KCl 20 mEq 1000 mL [HHSC]
|
Facility
|
IP
|
$14.79
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
2500774
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.57 |
| Max. Negotiated Rate |
$14.35 |
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: Cash Price |
$38.06
|
| Rate for Payer: Health Management Network Commercial |
$12.57
|
| Rate for Payer: Health Management Network Commercial |
$49.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.70
|
| Rate for Payer: MDX Hawaii PPO |
$56.80
|
| Rate for Payer: MDX Hawaii PPO |
$14.35
|
|
|
Sodium Chloride 0.9%- KCl 20 mEq 1000 mL [HHSC]
|
Facility
|
OP
|
$14.79
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
2500774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$14.35 |
| Rate for Payer: AlohaCare Medicaid |
$7.39
|
| Rate for Payer: AlohaCare Medicaid |
$29.28
|
| Rate for Payer: AlohaCare Medicare |
$29.28
|
| Rate for Payer: AlohaCare Medicare |
$7.39
|
| Rate for Payer: Cash Price |
$38.06
|
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: Cash Price |
$9.61
|
| Rate for Payer: Cash Price |
$38.06
|
| Rate for Payer: Devoted Health Medicare |
$8.13
|
| Rate for Payer: Devoted Health Medicare |
$32.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.63
|
| Rate for Payer: Health Management Network Commercial |
$49.78
|
| Rate for Payer: Health Management Network Commercial |
$12.57
|
| Rate for Payer: Humana Medicare |
$7.39
|
| Rate for Payer: Humana Medicare |
$29.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.28
|
| Rate for Payer: MDX Hawaii PPO |
$14.35
|
| Rate for Payer: MDX Hawaii PPO |
$56.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.28
|
| Rate for Payer: University Health Alliance Commercial |
$10.78
|
| Rate for Payer: University Health Alliance Commercial |
$42.68
|
|
|
sodium chloride 1 gm tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 69367022001
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 69367022001
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 77333084410
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00223176001
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 77333083510
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 77333083510
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00223176001
|
| Hospital Charge Code |
2500777
|
|
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 1 gm tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 77333084410
|
| Hospital Charge Code |
2500777
|
|
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% 500 ml [HHSC]
|
Facility
|
OP
|
$26.69
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
2500780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$25.89 |
| Rate for Payer: AlohaCare Medicaid |
$13.35
|
| Rate for Payer: AlohaCare Medicaid |
$19.82
|
| Rate for Payer: AlohaCare Medicaid |
$10.87
|
| Rate for Payer: AlohaCare Medicare |
$19.82
|
| Rate for Payer: AlohaCare Medicare |
$13.35
|
| Rate for Payer: AlohaCare Medicare |
$10.87
|
| Rate for Payer: Cash Price |
$25.77
|
| Rate for Payer: Cash Price |
$14.13
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Devoted Health Medicare |
$21.81
|
| Rate for Payer: Devoted Health Medicare |
$14.68
|
| Rate for Payer: Devoted Health Medicare |
$11.96
|
| 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 |
$20.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.36
|
| 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 |
$10.87
|
| Rate for Payer: Humana Medicare |
$19.82
|
| Rate for Payer: Humana Medicare |
$13.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.61
|
| 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 |
$13.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.82
|
| 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 |
$10.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.35
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.87
|
| 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 3% 500 ml [HHSC]
|
Facility
|
IP
|
$39.65
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
2500780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.70 |
| Max. Negotiated Rate |
$38.46 |
| Rate for Payer: Cash Price |
$25.77
|
| Rate for Payer: Cash Price |
$17.35
|
| Rate for Payer: Cash Price |
$14.13
|
| 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 |
$24.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.69
|
| Rate for Payer: MDX Hawaii PPO |
$21.09
|
| Rate for Payer: MDX Hawaii PPO |
$25.89
|
| Rate for Payer: MDX Hawaii PPO |
$38.46
|
|
|
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 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 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 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 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
|
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
|
$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
|
|
