|
ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 00574402450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$609.00
|
|
|
Service Code
|
NDC 62559063001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.79 |
| Max. Negotiated Rate |
$590.73 |
| Rate for Payer: AlohaCare Medicaid |
$304.50
|
| Rate for Payer: AlohaCare Medicare |
$188.79
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Devoted Health Medicare |
$207.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$188.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$578.55
|
| Rate for Payer: Health Management Network Commercial |
$517.65
|
| Rate for Payer: Humana Medicare |
$188.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$548.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$310.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$188.79
|
| Rate for Payer: MDX Hawaii PPO |
$590.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$188.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$188.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$188.79
|
| Rate for Payer: University Health Alliance Commercial |
$443.90
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 52536013213
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 52536013413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 52536013213
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
IP
|
$609.00
|
|
|
Service Code
|
NDC 62559063001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$517.65 |
| Max. Negotiated Rate |
$590.73 |
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Health Management Network Commercial |
$517.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$548.10
|
| Rate for Payer: MDX Hawaii PPO |
$590.73
|
|
|
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION [2899]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 52536013413
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG/10ML IV (WET SOLR VIAL) [4302903]
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS J1364
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$64.02 |
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$274.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.70
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
|
|
ERYTHROMYCIN LACTOBIONATE 500 MG/10ML IV (WET SOLR VIAL) [4302903]
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS J1364
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: AlohaCare Medicaid |
$33.00
|
| Rate for Payer: AlohaCare Medicaid |
$76.50
|
| Rate for Payer: AlohaCare Medicaid |
$152.50
|
| Rate for Payer: AlohaCare Medicare |
$94.55
|
| Rate for Payer: AlohaCare Medicare |
$47.43
|
| Rate for Payer: AlohaCare Medicare |
$20.46
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Cash Price |
$39.60
|
| Rate for Payer: Devoted Health Medicare |
$22.44
|
| Rate for Payer: Devoted Health Medicare |
$52.02
|
| Rate for Payer: Devoted Health Medicare |
$103.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$94.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association Non-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: Hawaii Western Management Group Commercial |
$62.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$289.75
|
| Rate for Payer: Health Management Network Commercial |
$259.25
|
| Rate for Payer: Health Management Network Commercial |
$56.10
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Humana Medicare |
$47.43
|
| Rate for Payer: Humana Medicare |
$20.46
|
| Rate for Payer: Humana Medicare |
$94.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$274.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$59.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$33.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$155.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$94.55
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
| Rate for Payer: MDX Hawaii PPO |
$64.02
|
| Rate for Payer: MDX Hawaii PPO |
$295.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$94.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$94.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$91.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$183.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$39.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$94.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.46
|
| Rate for Payer: University Health Alliance Commercial |
$48.11
|
| Rate for Payer: University Health Alliance Commercial |
$111.52
|
| Rate for Payer: University Health Alliance Commercial |
$222.31
|
|
|
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: Kaiser Permanente Commercial |
$137.70
|
| 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 |
$47.43 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: AlohaCare Medicaid |
$76.50
|
| Rate for Payer: AlohaCare Medicare |
$47.43
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Devoted Health Medicare |
$52.02
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$75.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.43
|
| 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: Humana Medicare |
$47.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.43
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$91.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.43
|
| 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: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
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: Kaiser Permanente Commercial |
$14.40
|
| 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 |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
ESCITALOPRAM 10 MG TABLET [33512]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 68084061701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| 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 |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| 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: Kaiser Permanente Commercial |
$14.40
|
| 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 |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
ESCITALOPRAM 20 MG TABLET [33513]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 68001045600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: AlohaCare Medicaid |
$8.00
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Devoted Health Medicare |
$5.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
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: Kaiser Permanente Commercial |
$15.30
|
| 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: Kaiser Permanente Commercial |
$14.40
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
ESCITALOPRAM 20 MG TABLET [33513]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 68084061801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
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: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION [82085]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J1805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicaid |
$18.50
|
| Rate for Payer: AlohaCare Medicare |
$11.47
|
| Rate for Payer: AlohaCare Medicare |
$8.37
|
| 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: Devoted Health Medicare |
$9.18
|
| Rate for Payer: Devoted Health Medicare |
$12.58
|
| 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 Medicare |
$8.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.47
|
| 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 |
$31.45
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Humana Medicare |
$8.37
|
| Rate for Payer: Humana Medicare |
$11.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.37
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.47
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
| Rate for Payer: University Health Alliance Commercial |
$26.97
|
|
|
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: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$33.30
|
| Rate for Payer: MDX Hawaii PPO |
$35.89
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
|
