|
ER STRAPPING WRIST/ELBOW Charge
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS 29260
|
| Hospital Charge Code |
440292600
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$120.12 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$143.00
|
| Rate for Payer: AlohaCare Medicare |
$120.12
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Cash Price |
$185.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$263.12
|
| Rate for Payer: Devoted Health Medicare |
$120.12
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$120.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$271.70
|
| Rate for Payer: Health Management Network Commercial |
$243.10
|
| Rate for Payer: Humana Medicare |
$120.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$257.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$120.12
|
| Rate for Payer: MDX Hawaii PPO |
$277.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$120.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$120.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$120.12
|
| Rate for Payer: University Health Alliance Commercial |
$208.47
|
|
|
ertapenem 1 g Inj [KMC]
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
|
|
ertapenem 1 g Inj [KMC]
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS J1335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.71 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: AlohaCare Medicaid |
$300.00
|
| Rate for Payer: AlohaCare Medicare |
$252.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$552.00
|
| Rate for Payer: Devoted Health Medicare |
$252.00
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$59.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$252.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$570.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Humana Medicare |
$252.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$252.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$252.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$252.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$360.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$252.00
|
| Rate for Payer: University Health Alliance Commercial |
$437.34
|
|
|
ER TPA ADMIN CVA Charge
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
HCPCS 37195
|
| Hospital Charge Code |
440371950
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$394.80 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$470.00
|
| Rate for Payer: AlohaCare Medicare |
$394.80
|
| Rate for Payer: Cash Price |
$611.00
|
| Rate for Payer: Cash Price |
$611.00
|
| Rate for Payer: Cash Price |
$611.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$864.80
|
| Rate for Payer: Devoted Health Medicare |
$394.80
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$394.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$893.00
|
| Rate for Payer: Health Management Network Commercial |
$799.00
|
| Rate for Payer: Humana Medicare |
$394.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$846.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$394.80
|
| Rate for Payer: MDX Hawaii PPO |
$911.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$394.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$394.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$394.80
|
| Rate for Payer: University Health Alliance Commercial |
$685.17
|
|
|
ER TPA ADMIN CVA Charge
|
Facility
|
IP
|
$940.00
|
|
|
Service Code
|
HCPCS 37195
|
| Hospital Charge Code |
440371950
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$799.00 |
| Max. Negotiated Rate |
$911.80 |
| Rate for Payer: Cash Price |
$611.00
|
| Rate for Payer: Health Management Network Commercial |
$799.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$846.00
|
| Rate for Payer: MDX Hawaii PPO |
$911.80
|
|
|
ER TREAT RADIUS FRACTURE CHARGE
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 24650
|
| Hospital Charge Code |
440246500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
ER TREAT RADIUS FRACTURE CHARGE
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 24650
|
| Hospital Charge Code |
440246500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
ER TREAT WRIST DISLOCATION Charge
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 25675
|
| Hospital Charge Code |
440256750
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
ER TREAT WRIST DISLOCATION Charge
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 25675
|
| Hospital Charge Code |
440256750
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
ER TX HIP DISLOCATION Charge
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 27256
|
| Hospital Charge Code |
440272560
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
ER TX HIP DISLOCATION Charge
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 27256
|
| Hospital Charge Code |
440272560
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
erythromycin Ophth 0.5% Oint [KMC]
|
Facility
|
OP
|
$13.71
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: AlohaCare Medicaid |
$6.86
|
| Rate for Payer: AlohaCare Medicare |
$5.76
|
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$12.61
|
| Rate for Payer: Devoted Health Medicare |
$5.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.02
|
| Rate for Payer: Health Management Network Commercial |
$11.65
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.76
|
| Rate for Payer: MDX Hawaii PPO |
$13.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.76
|
| Rate for Payer: University Health Alliance Commercial |
$9.99
|
|
|
erythromycin Ophth 0.5% Oint [KMC]
|
Facility
|
IP
|
$13.71
|
|
|
Service Code
|
NDC 24208091055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.65 |
| Max. Negotiated Rate |
$13.30 |
| Rate for Payer: Cash Price |
$8.91
|
| Rate for Payer: Health Management Network Commercial |
$11.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.30
|
|
|
Erythropoietin DLS
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
HCPCS 82668
|
| Hospital Charge Code |
422826685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.79 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: AlohaCare Medicaid |
$35.50
|
| Rate for Payer: AlohaCare Medicare |
$29.82
|
| Rate for Payer: Cash Price |
$46.15
|
| Rate for Payer: Cash Price |
$46.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$65.32
|
| Rate for Payer: Devoted Health Medicare |
$29.82
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$25.97
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$29.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.79
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Humana Medicare |
$29.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$29.82
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$29.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$29.82
|
| Rate for Payer: University Health Alliance Commercial |
$48.58
|
|
|
Erythropoietin DLS
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
HCPCS 82668
|
| Hospital Charge Code |
422826685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.35 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Cash Price |
$46.15
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
|
|
escitalopram 10 mg Tab [KMC]
|
Facility
|
IP
|
$17.52
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$16.99 |
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Health Management Network Commercial |
$14.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.77
|
| Rate for Payer: MDX Hawaii PPO |
$16.99
|
|
|
escitalopram 10 mg Tab [KMC]
|
Facility
|
OP
|
$17.52
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.36 |
| Max. Negotiated Rate |
$16.99 |
| Rate for Payer: AlohaCare Medicaid |
$8.76
|
| Rate for Payer: AlohaCare Medicare |
$7.36
|
| Rate for Payer: Cash Price |
$11.39
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$16.12
|
| Rate for Payer: Devoted Health Medicare |
$7.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.64
|
| Rate for Payer: Health Management Network Commercial |
$14.89
|
| Rate for Payer: Humana Medicare |
$7.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.36
|
| Rate for Payer: MDX Hawaii PPO |
$16.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.36
|
| Rate for Payer: University Health Alliance Commercial |
$12.77
|
|
|
escitalopram 5 mg / 5 mL Oral Syringe [KMC]
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
NDC 65162070588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.69 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Health Management Network Commercial |
$2.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.85
|
| Rate for Payer: MDX Hawaii PPO |
$3.07
|
|
|
escitalopram 5 mg / 5 mL Oral Syringe [KMC]
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
NDC 65162070588
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$3.07 |
| Rate for Payer: AlohaCare Medicaid |
$1.58
|
| Rate for Payer: AlohaCare Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2.92
|
| Rate for Payer: Devoted Health Medicare |
$1.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.01
|
| Rate for Payer: Health Management Network Commercial |
$2.69
|
| Rate for Payer: Humana Medicare |
$1.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.33
|
| Rate for Payer: MDX Hawaii PPO |
$3.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.33
|
| Rate for Payer: University Health Alliance Commercial |
$2.31
|
|
|
escitalopram 5 mg Tab [KMC]
|
Facility
|
IP
|
$16.60
|
|
|
Service Code
|
NDC 43547028010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$16.10 |
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Health Management Network Commercial |
$14.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.94
|
| Rate for Payer: MDX Hawaii PPO |
$16.10
|
|
|
escitalopram 5 mg Tab [KMC]
|
Facility
|
OP
|
$16.60
|
|
|
Service Code
|
NDC 43547028010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$16.10 |
| Rate for Payer: AlohaCare Medicaid |
$8.30
|
| Rate for Payer: AlohaCare Medicare |
$6.97
|
| Rate for Payer: Cash Price |
$10.79
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$15.27
|
| Rate for Payer: Devoted Health Medicare |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.77
|
| Rate for Payer: Health Management Network Commercial |
$14.11
|
| Rate for Payer: Humana Medicare |
$6.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.97
|
| Rate for Payer: MDX Hawaii PPO |
$16.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.97
|
| Rate for Payer: University Health Alliance Commercial |
$12.10
|
|
|
esomeprazole 40 mg DR cap [KMC]
|
Facility
|
OP
|
$35.34
|
|
|
Service Code
|
NDC 16714073601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$34.28 |
| Rate for Payer: AlohaCare Medicaid |
$17.67
|
| Rate for Payer: AlohaCare Medicare |
$14.84
|
| Rate for Payer: Cash Price |
$22.97
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$32.51
|
| Rate for Payer: Devoted Health Medicare |
$14.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.57
|
| Rate for Payer: Health Management Network Commercial |
$30.04
|
| Rate for Payer: Humana Medicare |
$14.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.84
|
| Rate for Payer: MDX Hawaii PPO |
$34.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.84
|
| Rate for Payer: University Health Alliance Commercial |
$25.76
|
|
|
esomeprazole 40 mg DR cap [KMC]
|
Facility
|
IP
|
$35.34
|
|
|
Service Code
|
NDC 16714073601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.04 |
| Max. Negotiated Rate |
$34.28 |
| Rate for Payer: Cash Price |
$22.97
|
| Rate for Payer: Health Management Network Commercial |
$30.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$31.81
|
| Rate for Payer: MDX Hawaii PPO |
$34.28
|
|
|
esomeprazole 40 mg powder packet [KMC]
|
Facility
|
IP
|
$39.02
|
|
|
Service Code
|
NDC 69097052934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.17 |
| Max. Negotiated Rate |
$37.85 |
| Rate for Payer: Cash Price |
$25.36
|
| Rate for Payer: Health Management Network Commercial |
$33.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.12
|
| Rate for Payer: MDX Hawaii PPO |
$37.85
|
|
|
esomeprazole 40 mg powder packet [KMC]
|
Facility
|
OP
|
$39.02
|
|
|
Service Code
|
NDC 69097052934
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.39 |
| Max. Negotiated Rate |
$37.85 |
| Rate for Payer: AlohaCare Medicaid |
$19.51
|
| Rate for Payer: AlohaCare Medicare |
$16.39
|
| Rate for Payer: Cash Price |
$25.36
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$35.90
|
| Rate for Payer: Devoted Health Medicare |
$16.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.07
|
| Rate for Payer: Health Management Network Commercial |
$33.17
|
| Rate for Payer: Humana Medicare |
$16.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.39
|
| Rate for Payer: MDX Hawaii PPO |
$37.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.39
|
| Rate for Payer: University Health Alliance Commercial |
$28.44
|
|