|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$47.06
|
|
|
Service Code
|
NDC 00409555502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$45.65 |
| Rate for Payer: Cash Price |
$30.59
|
| Rate for Payer: Health Management Network Commercial |
$40.00
|
| Rate for Payer: MDX Hawaii PPO |
$45.65
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$45.39
|
|
|
Service Code
|
NDC 51754501201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$44.03 |
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.12
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.15
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.23
|
| Rate for Payer: University Health Alliance Commercial |
$33.08
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$115.42
|
|
|
Service Code
|
NDC 63323008305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.86 |
| Max. Negotiated Rate |
$111.96 |
| Rate for Payer: Cash Price |
$75.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$98.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.86
|
| Rate for Payer: MDX Hawaii PPO |
$111.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.25
|
| Rate for Payer: University Health Alliance Commercial |
$84.13
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$47.06
|
|
|
Service Code
|
NDC 00409555512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$45.65 |
| Rate for Payer: Cash Price |
$30.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.71
|
| Rate for Payer: Health Management Network Commercial |
$40.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.00
|
| Rate for Payer: MDX Hawaii PPO |
$45.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.24
|
| Rate for Payer: University Health Alliance Commercial |
$34.30
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$45.39
|
|
|
Service Code
|
NDC 51754501204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$44.03 |
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$45.39
|
|
|
Service Code
|
NDC 51754501201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.58 |
| Max. Negotiated Rate |
$44.03 |
| Rate for Payer: Cash Price |
$29.50
|
| Rate for Payer: Health Management Network Commercial |
$38.58
|
| Rate for Payer: MDX Hawaii PPO |
$44.03
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
OP
|
$47.06
|
|
|
Service Code
|
NDC 00409555502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.00 |
| Max. Negotiated Rate |
$45.65 |
| Rate for Payer: Cash Price |
$30.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.71
|
| Rate for Payer: Health Management Network Commercial |
$40.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.00
|
| Rate for Payer: MDX Hawaii PPO |
$45.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.24
|
| Rate for Payer: University Health Alliance Commercial |
$34.30
|
|
|
SODIUM BICARBONATE 4.2 % IV SOLN
|
Facility
|
IP
|
$47.06
|
|
|
Service Code
|
NDC 00409555512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$45.65 |
| Rate for Payer: Cash Price |
$30.59
|
| Rate for Payer: Health Management Network Commercial |
$40.00
|
| Rate for Payer: MDX Hawaii PPO |
$45.65
|
|
|
SODIUM BICARBONATE 650 MG PO TABLET
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
|
|
SODIUM BICARBONATE 650 MG PO TABLET
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$1.16 |
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.14
|
| Rate for Payer: Health Management Network Commercial |
$1.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.61
|
| Rate for Payer: MDX Hawaii PPO |
$1.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.72
|
| Rate for Payer: University Health Alliance Commercial |
$0.87
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYR
|
Facility
|
IP
|
$99.56
|
|
|
Service Code
|
NDC 76329335201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.63 |
| Max. Negotiated Rate |
$96.57 |
| Rate for Payer: Cash Price |
$64.71
|
| Rate for Payer: Health Management Network Commercial |
$84.63
|
| Rate for Payer: MDX Hawaii PPO |
$96.57
|
|
|
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYR
|
Facility
|
OP
|
$99.56
|
|
|
Service Code
|
NDC 76329335201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.78 |
| Max. Negotiated Rate |
$96.57 |
| Rate for Payer: Cash Price |
$64.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.58
|
| Rate for Payer: Health Management Network Commercial |
$84.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$62.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.78
|
| Rate for Payer: MDX Hawaii PPO |
$96.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.74
|
| Rate for Payer: University Health Alliance Commercial |
$72.57
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
OP
|
$51.92
|
|
|
Service Code
|
NDC 51754500101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$50.36 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.32
|
| Rate for Payer: Health Management Network Commercial |
$44.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.48
|
| Rate for Payer: MDX Hawaii PPO |
$50.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.15
|
| Rate for Payer: University Health Alliance Commercial |
$37.84
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
IP
|
$57.24
|
|
|
Service Code
|
NDC 00409662514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.65 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Cash Price |
$37.21
|
| Rate for Payer: Health Management Network Commercial |
$48.65
|
| Rate for Payer: MDX Hawaii PPO |
$55.52
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
IP
|
$51.92
|
|
|
Service Code
|
NDC 51754500101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.13 |
| Max. Negotiated Rate |
$50.36 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Health Management Network Commercial |
$44.13
|
| Rate for Payer: MDX Hawaii PPO |
$50.36
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
OP
|
$57.24
|
|
|
Service Code
|
NDC 00409662514
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.19 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Cash Price |
$37.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.38
|
| Rate for Payer: Health Management Network Commercial |
$48.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.19
|
| Rate for Payer: MDX Hawaii PPO |
$55.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.34
|
| Rate for Payer: University Health Alliance Commercial |
$41.72
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
OP
|
$57.24
|
|
|
Service Code
|
NDC 00409662522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.19 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Cash Price |
$37.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.38
|
| Rate for Payer: Health Management Network Commercial |
$48.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.19
|
| Rate for Payer: MDX Hawaii PPO |
$55.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.34
|
| Rate for Payer: University Health Alliance Commercial |
$41.72
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
IP
|
$51.92
|
|
|
Service Code
|
NDC 51754500104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.13 |
| Max. Negotiated Rate |
$50.36 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Health Management Network Commercial |
$44.13
|
| Rate for Payer: MDX Hawaii PPO |
$50.36
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
IP
|
$51.92
|
|
|
Service Code
|
NDC 51754500105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.13 |
| Max. Negotiated Rate |
$50.36 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Health Management Network Commercial |
$44.13
|
| Rate for Payer: MDX Hawaii PPO |
$50.36
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
OP
|
$51.92
|
|
|
Service Code
|
NDC 51754500105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$50.36 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.32
|
| Rate for Payer: Health Management Network Commercial |
$44.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.48
|
| Rate for Payer: MDX Hawaii PPO |
$50.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.15
|
| Rate for Payer: University Health Alliance Commercial |
$37.84
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
IP
|
$57.24
|
|
|
Service Code
|
NDC 00409662522
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.65 |
| Max. Negotiated Rate |
$55.52 |
| Rate for Payer: Cash Price |
$37.21
|
| Rate for Payer: Health Management Network Commercial |
$48.65
|
| Rate for Payer: MDX Hawaii PPO |
$55.52
|
|
|
SODIUM BICARBONATE 8.4 % IV SOLN
|
Facility
|
OP
|
$51.92
|
|
|
Service Code
|
NDC 51754500104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.48 |
| Max. Negotiated Rate |
$50.36 |
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.32
|
| Rate for Payer: Health Management Network Commercial |
$44.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$32.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.48
|
| Rate for Payer: MDX Hawaii PPO |
$50.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.15
|
| Rate for Payer: University Health Alliance Commercial |
$37.84
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
|
OP
|
$28.98
|
|
|
Service Code
|
NDC 00990798502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: Cash Price |
$18.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.53
|
| Rate for Payer: Health Management Network Commercial |
$24.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.78
|
| Rate for Payer: MDX Hawaii PPO |
$28.11
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.39
|
| Rate for Payer: University Health Alliance Commercial |
$21.12
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
|
IP
|
$28.98
|
|
|
Service Code
|
NDC 00990798502
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.63 |
| Max. Negotiated Rate |
$28.11 |
| Rate for Payer: Cash Price |
$18.84
|
| Rate for Payer: Health Management Network Commercial |
$24.63
|
| Rate for Payer: MDX Hawaii PPO |
$28.11
|
|
|
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP
|
Facility
|
IP
|
$22.08
|
|
|
Service Code
|
NDC 00264780200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Cash Price |
$14.35
|
| Rate for Payer: Health Management Network Commercial |
$18.77
|
| Rate for Payer: MDX Hawaii PPO |
$21.42
|
|
