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All Charges

Charge

Type

Setting

Price

ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]

Facility

IP

$153.00

Service Code	HCPCS J1364
Hospital Revenue Code	250
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: MDX Hawaii PPO	$148.41

ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION [2903]

Facility

OP

$153.00

Service Code	HCPCS J1364
Hospital Revenue Code	636
Min. Negotiated Rate	$75.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cash Price	$91.80
Rate for Payer: Hawaii Medical Service Association ABD	$75.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$75.05
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$96.39
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: UnitedHealthcare Medicaid	$91.80
Rate for Payer: University Health Alliance Commercial	$111.52

ESCITALOPRAM 10 MG TABLET [33512]

Facility

IP

$16.00

Service Code	NDC 00904642661
Hospital Revenue Code	250
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

ESCITALOPRAM 10 MG TABLET [33512]

Facility

OP

$16.00

Service Code	NDC 68084061701
Hospital Revenue Code	637
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

ESCITALOPRAM 10 MG TABLET [33512]

Facility

IP

$16.00

Service Code	NDC 68084061701
Hospital Revenue Code	250
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

ESCITALOPRAM 10 MG TABLET [33512]

Facility

OP

$16.00

Service Code	NDC 00904642661
Hospital Revenue Code	637
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

ESCITALOPRAM 20 MG TABLET [33513]

Facility

IP

$16.00

Service Code	NDC 68001059300
Hospital Revenue Code	250
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

ESCITALOPRAM 20 MG TABLET [33513]

Facility

IP

$17.00

Service Code	NDC 68084061801
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

ESCITALOPRAM 20 MG TABLET [33513]

Facility

IP

$16.00

Service Code	NDC 68001045600
Hospital Revenue Code	250
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

ESCITALOPRAM 20 MG TABLET [33513]

Facility

OP

$17.00

Service Code	NDC 68084061811
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

ESCITALOPRAM 20 MG TABLET [33513]

Facility

OP

$17.00

Service Code	NDC 68084061801
Hospital Revenue Code	637
Min. Negotiated Rate	$8.67
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: University Health Alliance Commercial	$12.39

ESCITALOPRAM 20 MG TABLET [33513]

Facility

IP

$17.00

Service Code	NDC 68084061811
Hospital Revenue Code	250
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$16.49

ESCITALOPRAM 20 MG TABLET [33513]

Facility

OP

$16.00

Service Code	NDC 68001045600
Hospital Revenue Code	637
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

ESCITALOPRAM 20 MG TABLET [33513]

Facility

OP

$16.00

Service Code	NDC 68001059300
Hospital Revenue Code	637
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

ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [82085]

Facility

IP

$27.00

Service Code	HCPCS J1805
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$22.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: MDX Hawaii PPO	$35.89

ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [82085]

Facility

OP

$37.00

Service Code	HCPCS J1805
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$35.89
Rate for Payer: Cash Price	$22.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cash Price	$22.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.28
Rate for Payer: Hawaii Medical Service Association ABD	$0.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.28
Rate for Payer: Hawaii Western Management Group Commercial	$25.65
Rate for Payer: Hawaii Western Management Group Commercial	$35.15
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Health Management Network Commercial	$31.45
Rate for Payer: Kaiser Permanente Commercial	$23.31
Rate for Payer: Kaiser Permanente Commercial	$17.01
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicaid	$18.87
Rate for Payer: MDX Hawaii PPO	$35.89
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: UnitedHealthcare Medicaid	$16.20
Rate for Payer: UnitedHealthcare Medicaid	$22.20
Rate for Payer: University Health Alliance Commercial	$19.68
Rate for Payer: University Health Alliance Commercial	$26.97

ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]

Facility

OP

$567.00

Service Code	HCPCS J1805
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$549.99
Rate for Payer: Cash Price	$340.20
Rate for Payer: Cash Price	$340.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.28
Rate for Payer: Hawaii Western Management Group Commercial	$538.65
Rate for Payer: Health Management Network Commercial	$481.95
Rate for Payer: Kaiser Permanente Commercial	$357.21
Rate for Payer: Kaiser Permanente Medicaid	$289.17
Rate for Payer: MDX Hawaii PPO	$549.99
Rate for Payer: UnitedHealthcare Medicaid	$340.20
Rate for Payer: University Health Alliance Commercial	$413.29

ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV [29805]

Facility

IP

$567.00

Service Code	HCPCS J1805
Hospital Revenue Code	250
Min. Negotiated Rate	$481.95
Max. Negotiated Rate	$549.99
Rate for Payer: Cash Price	$340.20
Rate for Payer: Health Management Network Commercial	$481.95
Rate for Payer: MDX Hawaii PPO	$549.99

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

IP

$21,878.17

Service Code	MSDRG 391
Min. Negotiated Rate	$14,425.95
Max. Negotiated Rate	$21,878.17
Rate for Payer: AlohaCare Medicare	$14,425.95
Rate for Payer: Devoted Health Medicare	$15,868.55
Rate for Payer: Hawaii Medical Service Association Commercial	$17,325.92
Rate for Payer: Hawaii Medical Service Association Medicare	$14,425.95
Rate for Payer: Humana Medicare	$14,425.95
Rate for Payer: Kaiser Permanente Commercial	$21,878.17
Rate for Payer: Kaiser Permanente Medicare	$14,425.95
Rate for Payer: Ohana Health Plan Medicare	$14,425.95
Rate for Payer: UnitedHealthcare Medicare	$14,425.95

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

IP

$14,899.32

Service Code	MSDRG 392
Min. Negotiated Rate	$8,867.37
Max. Negotiated Rate	$14,899.32
Rate for Payer: AlohaCare Medicare	$8,867.37
Rate for Payer: Devoted Health Medicare	$9,754.11
Rate for Payer: Hawaii Medical Service Association Commercial	$14,899.32
Rate for Payer: Hawaii Medical Service Association Medicare	$8,867.37
Rate for Payer: Humana Medicare	$8,867.37
Rate for Payer: Kaiser Permanente Commercial	$13,448.10
Rate for Payer: Kaiser Permanente Medicare	$8,867.37
Rate for Payer: Ohana Health Plan Medicare	$8,867.37
Rate for Payer: UnitedHealthcare Medicare	$8,867.37

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES

Facility

OP

$5,509.00

Service Code	CPT 43244
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE

Facility

OP

$5,509.00

Service Code	CPT 43246
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,266.89
Rate for Payer: AlohaCare Medicare	$2,266.89
Rate for Payer: Devoted Health Medicare	$2,493.58
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,266.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,266.89
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,266.89
Rate for Payer: Ohana Health Plan Medicaid	$2,493.58
Rate for Payer: Ohana Health Plan Medicare	$2,266.89
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,266.89
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S)

Facility

OP

$5,509.00

Service Code	CPT 43247
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,071.46
Rate for Payer: AlohaCare Medicare	$1,071.46
Rate for Payer: Devoted Health Medicare	$1,178.61
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,071.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,071.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,071.46
Rate for Payer: Ohana Health Plan Medicaid	$1,178.61
Rate for Payer: Ohana Health Plan Medicare	$1,071.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,071.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH MUCOSAL ATTACHED TELEMETRY PH ELECTRODE PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION

Facility

OP

$4,035.20

Service Code	CPT 91035
Hospital Revenue Code	360
Min. Negotiated Rate	$375.51
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,014.47
Rate for Payer: AlohaCare Medicare	$1,014.47
Rate for Payer: Devoted Health Medicare	$1,115.92
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,014.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,014.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,014.47
Rate for Payer: Ohana Health Plan Medicaid	$1,115.92
Rate for Payer: Ohana Health Plan Medicare	$1,014.47
Rate for Payer: UnitedHealthcare Medicaid	$375.51
Rate for Payer: UnitedHealthcare Medicare	$1,014.47
Rate for Payer: University Health Alliance Commercial	$4,035.20

ESOPH BALLN 5.5FRX10-20MM

Facility

IP

$825.00

Service Code	HCPCS C1726
Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

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