|
SODIUM 35 MEQ-POTASSIUM 20 MEQ-MAG 5 MEQ/20 ML-CALCIUM-CHLORID-ACET IV [5740]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
NDC 00409577911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
|
|
SODIUM 35 MEQ-POTASSIUM 20 MEQ-MAG 5 MEQ/20 ML-CALCIUM-CHLORID-ACET IV [5740]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
NDC 00409577901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 00409729983
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION [7301]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 00409729973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION [7309]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 00409662514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE [201436]
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 00409553414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [201437]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 76329335201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.00 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
|
|
SODIUM BICARBONATE 50 MEQ/50 ML (8.4 %) INTRAVENOUS SYRINGE [201437]
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
NDC 00409663714
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.40 |
| Max. Negotiated Rate |
$62.08 |
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Health Management Network Commercial |
$54.40
|
| Rate for Payer: MDX Hawaii PPO |
$62.08
|
|
|
SODIUM BICARBONATE 650 MG TABLET [7313]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 69367025810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SODIUM BICARBONATE 650 MG TABLET [7313]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904726161
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SODIUM BICARBONATE 650 MG TABLET [7313]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 64980052810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SODIUM BICARBONATE 650 MG TABLET [7313]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 64980052810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SODIUM BICARBONATE 650 MG TABLET [7313]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 69367025810
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SODIUM BICARBONATE 650 MG TABLET [7313]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904726161
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00264780210
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00264580400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264580400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00264780200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264780200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION [7318]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00264780210
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
SODIUM CHLORIDE 0.45 % IV BOLUS [400292]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 00264780200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
SODIUM CHLORIDE 0.45 % IV BOLUS [400292]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264780200
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
SODIUM CHLORIDE 0.45 % IV BOLUS [400292]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 00264580400
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
SODIUM CHLORIDE 0.45 % IV BOLUS [400292]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 00264780210
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
SODIUM CHLORIDE 0.45 % IV BOLUS [400292]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 00264780210
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
