Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ROM Hand Charges

Facility

$179.00

Service Code	HCPCS 95852 GO
Hospital Charge Code	432958520
Hospital Revenue Code	430
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

ROM HAND Occupational

Facility

$179.00

Service Code	HCPCS 95852 GO
Hospital Charge Code	432958520
Hospital Revenue Code	430
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$5.33
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

ROM HAND Occupational

Facility

$179.00

Service Code	HCPCS 95852 GO
Hospital Charge Code	432958520
Hospital Revenue Code	430
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

romiPLOStim 125 mcg REC vial [KMC]

Facility

$6,607.34

Service Code	HCPCS J2802
Hospital Revenue Code	636
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$6,409.12
Rate for Payer: AlohaCare Medicaid	$3,303.67
Rate for Payer: AlohaCare Medicare	$2,775.08
Rate for Payer: Cash Price	$4,294.77
Rate for Payer: Cash Price	$4,294.77
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6,078.75
Rate for Payer: Devoted Health Medicare	$2,775.08
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13.89
Rate for Payer: Hawaii Medical Service Association Medicare	$2,775.08
Rate for Payer: Hawaii Western Management Group Commercial	$6,276.97
Rate for Payer: Health Management Network Commercial	$5,616.24
Rate for Payer: Humana Medicare	$2,775.08
Rate for Payer: Kaiser Permanente Commercial	$5,946.61
Rate for Payer: Kaiser Permanente Medicaid	$3,369.74
Rate for Payer: Kaiser Permanente Medicare	$2,775.08
Rate for Payer: MDX Hawaii PPO	$6,409.12
Rate for Payer: Ohana Health Plan Medicaid	$2,775.08
Rate for Payer: Ohana Health Plan Medicare	$2,775.08
Rate for Payer: UnitedHealthcare Medicaid	$3,964.40
Rate for Payer: UnitedHealthcare Medicare	$2,775.08
Rate for Payer: University Health Alliance Commercial	$4,816.09

romiPLOStim 125 mcg REC vial [KMC]

Facility

$6,607.34

Service Code	HCPCS J2802
Hospital Revenue Code	636
Min. Negotiated Rate	$5,616.24
Max. Negotiated Rate	$6,409.12
Rate for Payer: Cash Price	$4,294.77
Rate for Payer: Health Management Network Commercial	$5,616.24
Rate for Payer: Kaiser Permanente Commercial	$5,946.61
Rate for Payer: MDX Hawaii PPO	$6,409.12

ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPI

Professional

Both

$171.00

Service Code	HCPCS 95851
Hospital Revenue Code	420
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$145.35
Rate for Payer: AlohaCare Medicaid	$7.81
Rate for Payer: AlohaCare Medicare	$6.68
Rate for Payer: Cash Price	$111.15
Rate for Payer: Cash Price	$111.15
Rate for Payer: Devoted Health Medicare	$6.68
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.81
Rate for Payer: Hawaii Medical Service Association Medicare	$6.68
Rate for Payer: Hawaii Western Management Group Commercial	$17.04
Rate for Payer: Health Management Network Commercial	$145.35
Rate for Payer: Kaiser Permanente Commercial	$8.02
Rate for Payer: Kaiser Permanente Medicaid	$8.02
Rate for Payer: Kaiser Permanente Medicare	$8.02
Rate for Payer: Ohana Health Plan Medicaid	$7.81
Rate for Payer: Ohana Health Plan Medicare	$6.68
Rate for Payer: UnitedHealthcare Medicaid	$7.81
Rate for Payer: UnitedHealthcare Medicare	$6.68
Rate for Payer: University Health Alliance Commercial	$9.51

ROM MEAS&REPRT HAND W/WO COMPARISON NORMAL SID

Professional

Both

$171.00

Service Code	HCPCS 95852
Hospital Revenue Code	420
Min. Negotiated Rate	$5.01
Max. Negotiated Rate	$145.35
Rate for Payer: AlohaCare Medicaid	$5.38
Rate for Payer: AlohaCare Medicare	$5.01
Rate for Payer: Cash Price	$111.15
Rate for Payer: Cash Price	$111.15
Rate for Payer: Devoted Health Medicare	$5.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.38
Rate for Payer: Hawaii Medical Service Association Medicare	$5.01
Rate for Payer: Hawaii Western Management Group Commercial	$11.94
Rate for Payer: Health Management Network Commercial	$145.35
Rate for Payer: Kaiser Permanente Commercial	$6.01
Rate for Payer: Kaiser Permanente Medicaid	$6.01
Rate for Payer: Kaiser Permanente Medicare	$6.01
Rate for Payer: Ohana Health Plan Medicaid	$5.38
Rate for Payer: Ohana Health Plan Medicare	$5.01
Rate for Payer: UnitedHealthcare Medicaid	$5.38
Rate for Payer: UnitedHealthcare Medicare	$5.01
Rate for Payer: University Health Alliance Commercial	$6.57

ROM MEASURE EA EXT/TRUNK Occupational

Facility

$179.00

Service Code	HCPCS 95851 GO
Hospital Charge Code	426958510
Hospital Revenue Code	430
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

ROM MEASURE EA EXT/TRUNK Occupational

Facility

$179.00

Service Code	HCPCS 95851 GO
Hospital Charge Code	426958510
Hospital Revenue Code	430
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$7.89
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

ROM MEASURE EA EXT/TRUNK Physical

Facility

$179.00

Service Code	HCPCS 95851 GP
Hospital Charge Code	432958510
Hospital Revenue Code	420
Min. Negotiated Rate	$7.89
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$75.18
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$164.68
Rate for Payer: Devoted Health Medicare	$75.18
Rate for Payer: Hawaii Medical Service Association Medicare	$75.18
Rate for Payer: Hawaii Western Management Group Commercial	$170.05
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$75.18
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$75.18
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$75.18
Rate for Payer: Ohana Health Plan Medicare	$75.18
Rate for Payer: UnitedHealthcare Medicaid	$7.89
Rate for Payer: UnitedHealthcare Medicare	$75.18
Rate for Payer: University Health Alliance Commercial	$130.47

ROM MEASURE EA EXT/TRUNK Physical

Facility

$179.00

Service Code	HCPCS 95851 GP
Hospital Charge Code	432958510
Hospital Revenue Code	420
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

ROOM/BED: Hospice

Facility

$1,800.00

Hospital Charge Code	1701002
Hospital Revenue Code	658
Min. Negotiated Rate	$756.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: AlohaCare Medicaid	$900.00
Rate for Payer: AlohaCare Medicare	$756.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,656.00
Rate for Payer: Devoted Health Medicare	$756.00
Rate for Payer: Hawaii Medical Service Association Medicare	$756.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Humana Medicare	$756.00
Rate for Payer: Kaiser Permanente Commercial	$1,620.00
Rate for Payer: Kaiser Permanente Medicaid	$918.00
Rate for Payer: Kaiser Permanente Medicare	$756.00
Rate for Payer: MDX Hawaii PPO	$1,746.00
Rate for Payer: Ohana Health Plan Medicaid	$756.00
Rate for Payer: Ohana Health Plan Medicare	$756.00
Rate for Payer: UnitedHealthcare Medicare	$756.00
Rate for Payer: University Health Alliance Commercial	$1,312.02

ROOM/BED: Hospice

Facility

$1,800.00

Hospital Charge Code	1701002
Hospital Revenue Code	658
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Kaiser Permanente Commercial	$1,620.00
Rate for Payer: MDX Hawaii PPO	$1,746.00

ROOM/BED: Pediatric Private

Facility

$2,281.00

Hospital Charge Code	1401001
Hospital Revenue Code	111
Min. Negotiated Rate	$1,938.85
Max. Negotiated Rate	$7,250.00
Rate for Payer: AlohaCare Medicaid	$2,811.74
Rate for Payer: AlohaCare Medicare	$2,638.00
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,803.60
Rate for Payer: Devoted Health Medicare	$2,638.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2,811.74
Rate for Payer: Hawaii Medical Service Association Medicare	$2,638.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$1,938.85
Rate for Payer: Humana Medicare	$2,638.00
Rate for Payer: Kaiser Permanente Commercial	$2,052.90
Rate for Payer: Kaiser Permanente Medicaid	$2,811.74
Rate for Payer: Kaiser Permanente Medicare	$2,638.00
Rate for Payer: MDX Hawaii PPO	$2,212.57
Rate for Payer: Ohana Health Plan Medicaid	$2,811.74
Rate for Payer: Ohana Health Plan Medicare	$2,638.00
Rate for Payer: UnitedHealthcare Medicaid	$2,811.74
Rate for Payer: UnitedHealthcare Medicare	$2,638.00
Rate for Payer: University Health Alliance Commercial	$5,923.00

ROOM/BED: Private

Facility

$2,281.00

Hospital Charge Code	401100001
Hospital Revenue Code	111
Min. Negotiated Rate	$1,938.85
Max. Negotiated Rate	$7,250.00
Rate for Payer: AlohaCare Medicaid	$2,811.74
Rate for Payer: AlohaCare Medicare	$2,638.00
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,803.60
Rate for Payer: Devoted Health Medicare	$2,638.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2,811.74
Rate for Payer: Hawaii Medical Service Association Medicare	$2,638.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$1,938.85
Rate for Payer: Humana Medicare	$2,638.00
Rate for Payer: Kaiser Permanente Commercial	$2,052.90
Rate for Payer: Kaiser Permanente Medicaid	$2,811.74
Rate for Payer: Kaiser Permanente Medicare	$2,638.00
Rate for Payer: MDX Hawaii PPO	$2,212.57
Rate for Payer: Ohana Health Plan Medicaid	$2,811.74
Rate for Payer: Ohana Health Plan Medicare	$2,638.00
Rate for Payer: UnitedHealthcare Medicaid	$2,811.74
Rate for Payer: UnitedHealthcare Medicare	$2,638.00
Rate for Payer: University Health Alliance Commercial	$5,923.00

ROOM/BED: SNF

Facility

$2,281.00

Hospital Charge Code	400100001
Hospital Revenue Code	111
Min. Negotiated Rate	$1,938.85
Max. Negotiated Rate	$7,250.00
Rate for Payer: AlohaCare Medicaid	$2,811.74
Rate for Payer: AlohaCare Medicare	$2,638.00
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,803.60
Rate for Payer: Devoted Health Medicare	$2,638.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2,811.74
Rate for Payer: Hawaii Medical Service Association Medicare	$2,638.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,250.00
Rate for Payer: Health Management Network Commercial	$1,938.85
Rate for Payer: Humana Medicare	$2,638.00
Rate for Payer: Kaiser Permanente Commercial	$2,052.90
Rate for Payer: Kaiser Permanente Medicaid	$2,811.74
Rate for Payer: Kaiser Permanente Medicare	$2,638.00
Rate for Payer: MDX Hawaii PPO	$2,212.57
Rate for Payer: Ohana Health Plan Medicaid	$2,811.74
Rate for Payer: Ohana Health Plan Medicare	$2,638.00
Rate for Payer: UnitedHealthcare Medicaid	$2,811.74
Rate for Payer: UnitedHealthcare Medicare	$2,638.00
Rate for Payer: University Health Alliance Commercial	$5,923.00

ROOM/BED: Swing

Facility

$2,281.00

Hospital Charge Code	401100002
Hospital Revenue Code	111
Min. Negotiated Rate	$486.76
Max. Negotiated Rate	$5,923.00
Rate for Payer: AlohaCare Medicaid	$486.76
Rate for Payer: AlohaCare Medicare	$2,289.00
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Cash Price	$1,482.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,035.80
Rate for Payer: Devoted Health Medicare	$2,289.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$486.76
Rate for Payer: Hawaii Medical Service Association Commercial	$890.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,289.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,350.00
Rate for Payer: Health Management Network Commercial	$1,938.85
Rate for Payer: Humana Medicare	$2,289.00
Rate for Payer: Kaiser Permanente Commercial	$2,052.90
Rate for Payer: Kaiser Permanente Medicaid	$2,811.74
Rate for Payer: Kaiser Permanente Medicare	$2,289.00
Rate for Payer: MDX Hawaii PPO	$2,212.57
Rate for Payer: Ohana Health Plan Medicaid	$486.76
Rate for Payer: Ohana Health Plan Medicare	$2,289.00
Rate for Payer: UnitedHealthcare Medicaid	$2,811.74
Rate for Payer: UnitedHealthcare Medicare	$2,289.00
Rate for Payer: University Health Alliance Commercial	$5,923.00

rOPINIRole 0.25 mg Tab [KMC]

Facility

$10.02

Service Code	NDC 68462025301
Hospital Revenue Code	250
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$9.72
Rate for Payer: Cash Price	$6.51
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: MDX Hawaii PPO	$9.72

rOPINIRole 0.25 mg Tab [KMC]

Facility

$10.02

Service Code	NDC 68462025301
Hospital Revenue Code	250
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$9.72
Rate for Payer: AlohaCare Medicaid	$5.01
Rate for Payer: AlohaCare Medicare	$4.21
Rate for Payer: Cash Price	$6.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.22
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$4.21
Rate for Payer: Hawaii Western Management Group Commercial	$9.52
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Humana Medicare	$4.21
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: Kaiser Permanente Medicaid	$5.11
Rate for Payer: Kaiser Permanente Medicare	$4.21
Rate for Payer: MDX Hawaii PPO	$9.72
Rate for Payer: Ohana Health Plan Medicaid	$4.21
Rate for Payer: Ohana Health Plan Medicare	$4.21
Rate for Payer: UnitedHealthcare Medicaid	$6.01
Rate for Payer: UnitedHealthcare Medicare	$4.21
Rate for Payer: University Health Alliance Commercial	$7.30

rOPINIRole 0.5 mg Tab [KMC]

Facility

$10.02

Service Code	NDC 68462025401
Hospital Revenue Code	250
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$9.72
Rate for Payer: Cash Price	$6.51
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: MDX Hawaii PPO	$9.72

rOPINIRole 0.5 mg Tab [KMC]

Facility

$10.02

Service Code	NDC 68462025401
Hospital Revenue Code	250
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$9.72
Rate for Payer: AlohaCare Medicaid	$5.01
Rate for Payer: AlohaCare Medicare	$4.21
Rate for Payer: Cash Price	$6.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.22
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$4.21
Rate for Payer: Hawaii Western Management Group Commercial	$9.52
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Humana Medicare	$4.21
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: Kaiser Permanente Medicaid	$5.11
Rate for Payer: Kaiser Permanente Medicare	$4.21
Rate for Payer: MDX Hawaii PPO	$9.72
Rate for Payer: Ohana Health Plan Medicaid	$4.21
Rate for Payer: Ohana Health Plan Medicare	$4.21
Rate for Payer: UnitedHealthcare Medicaid	$6.01
Rate for Payer: UnitedHealthcare Medicare	$4.21
Rate for Payer: University Health Alliance Commercial	$7.30

rOPINIRole 1 mg Tab [KMC]

Facility

$10.02

Service Code	NDC 68462025501
Hospital Revenue Code	250
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$9.72
Rate for Payer: AlohaCare Medicaid	$5.01
Rate for Payer: AlohaCare Medicare	$4.21
Rate for Payer: Cash Price	$6.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.22
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$4.21
Rate for Payer: Hawaii Western Management Group Commercial	$9.52
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Humana Medicare	$4.21
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: Kaiser Permanente Medicaid	$5.11
Rate for Payer: Kaiser Permanente Medicare	$4.21
Rate for Payer: MDX Hawaii PPO	$9.72
Rate for Payer: Ohana Health Plan Medicaid	$4.21
Rate for Payer: Ohana Health Plan Medicare	$4.21
Rate for Payer: UnitedHealthcare Medicaid	$6.01
Rate for Payer: UnitedHealthcare Medicare	$4.21
Rate for Payer: University Health Alliance Commercial	$7.30

rOPINIRole 1 mg Tab [KMC]

Facility

$10.02

Service Code	NDC 68462025501
Hospital Revenue Code	250
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$9.72
Rate for Payer: Cash Price	$6.51
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: MDX Hawaii PPO	$9.72

rOPINIRole 2 mg Tab

Facility

$10.02

Service Code	NDC 68462025601
Hospital Revenue Code	250
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$9.72
Rate for Payer: AlohaCare Medicaid	$5.01
Rate for Payer: AlohaCare Medicare	$4.21
Rate for Payer: Cash Price	$6.51
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.22
Rate for Payer: Devoted Health Medicare	$4.21
Rate for Payer: Hawaii Medical Service Association Medicare	$4.21
Rate for Payer: Hawaii Western Management Group Commercial	$9.52
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Humana Medicare	$4.21
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: Kaiser Permanente Medicaid	$5.11
Rate for Payer: Kaiser Permanente Medicare	$4.21
Rate for Payer: MDX Hawaii PPO	$9.72
Rate for Payer: Ohana Health Plan Medicaid	$4.21
Rate for Payer: Ohana Health Plan Medicare	$4.21
Rate for Payer: UnitedHealthcare Medicaid	$6.01
Rate for Payer: UnitedHealthcare Medicare	$4.21
Rate for Payer: University Health Alliance Commercial	$7.30

rOPINIRole 2 mg Tab

Facility

$10.02

Service Code	NDC 68462025601
Hospital Revenue Code	250
Min. Negotiated Rate	$8.52
Max. Negotiated Rate	$9.72
Rate for Payer: Cash Price	$6.51
Rate for Payer: Health Management Network Commercial	$8.52
Rate for Payer: Kaiser Permanente Commercial	$9.02
Rate for Payer: MDX Hawaii PPO	$9.72

Know your out-of-pocket cost for care.

All Charges