|
PAIN & SPINE: THERMOGARD
|
Facility
|
IP
|
$188.00
|
|
| Hospital Charge Code |
9337527
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$159.80 |
| Max. Negotiated Rate |
$182.36 |
| Rate for Payer: Cash Price |
$122.20
|
| Rate for Payer: Health Management Network Commercial |
$159.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$169.20
|
| Rate for Payer: MDX Hawaii PPO |
$182.36
|
|
|
PAIN & SPINE VECTRIS PERM LEAD KIT
|
Facility
|
OP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,200.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,200.00
|
| Rate for Payer: AlohaCare Medicare |
$2,200.00
|
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Devoted Health Medicare |
$2,420.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,200.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,080.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Humana Medicare |
$2,200.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,960.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,244.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,200.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,200.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,200.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,200.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,464.00
|
|
|
PAIN & SPINE VECTRIS PERM LEAD KIT
|
Facility
|
IP
|
$4,400.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806287
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,464.00 |
| Max. Negotiated Rate |
$4,268.00 |
| Rate for Payer: Cash Price |
$2,860.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,080.00
|
| Rate for Payer: Health Management Network Commercial |
$3,740.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,960.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,268.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,464.00
|
|
|
PAIN & SPINE VECTRIS TRIAL LEAD KIT
|
Facility
|
IP
|
$2,700.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806286
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,512.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,890.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,512.00
|
|
|
PAIN & SPINE VECTRIS TRIAL LEAD KIT
|
Facility
|
OP
|
$2,700.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
8806286
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,350.00 |
| Max. Negotiated Rate |
$2,619.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,350.00
|
| Rate for Payer: AlohaCare Medicare |
$1,350.00
|
| Rate for Payer: Cash Price |
$1,755.00
|
| Rate for Payer: Devoted Health Medicare |
$1,485.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,350.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,890.00
|
| Rate for Payer: Health Management Network Commercial |
$2,295.00
|
| Rate for Payer: Humana Medicare |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,430.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,377.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,619.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,350.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,350.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,350.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,512.00
|
|
|
PAIN & SPINE: VIADISC NP INJECTION (100MG)
|
Facility
|
IP
|
$18,000.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
10674516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,080.00 |
| Max. Negotiated Rate |
$17,460.00 |
| Rate for Payer: Cash Price |
$11,700.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,600.00
|
| Rate for Payer: Health Management Network Commercial |
$15,300.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,200.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,460.00
|
| Rate for Payer: University Health Alliance Commercial |
$10,080.00
|
|
|
PAIN & SPINE: VIADISC NP INJECTION (100MG)
|
Facility
|
OP
|
$18,000.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
10674516
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,000.00 |
| Max. Negotiated Rate |
$17,460.00 |
| Rate for Payer: AlohaCare Medicaid |
$9,000.00
|
| Rate for Payer: AlohaCare Medicare |
$9,000.00
|
| Rate for Payer: Cash Price |
$11,700.00
|
| Rate for Payer: Devoted Health Medicare |
$9,900.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9,000.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,600.00
|
| Rate for Payer: Health Management Network Commercial |
$15,300.00
|
| Rate for Payer: Humana Medicare |
$9,000.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,200.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9,180.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$9,000.00
|
| Rate for Payer: MDX Hawaii PPO |
$17,460.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9,000.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$9,000.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9,000.00
|
| Rate for Payer: University Health Alliance Commercial |
$10,080.00
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC
|
Facility
|
IP
|
$55,555.78
|
|
|
Service Code
|
MSDRG 406
|
| Min. Negotiated Rate |
$55,555.78 |
| Max. Negotiated Rate |
$55,555.78 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$55,555.78
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC
|
Facility
|
IP
|
$100,505.23
|
|
|
Service Code
|
MSDRG 405
|
| Min. Negotiated Rate |
$100,505.23 |
| Max. Negotiated Rate |
$100,505.23 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$100,505.23
|
|
|
PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$39,824.75
|
|
|
Service Code
|
MSDRG 407
|
| Min. Negotiated Rate |
$39,824.75 |
| Max. Negotiated Rate |
$39,824.75 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39,824.75
|
|
|
PANCREAS TRANSPLANT
|
Facility
|
IP
|
$10,400.00
|
|
|
Service Code
|
MSDRG 010
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$10,400.00 |
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
IP
|
$89.17
|
|
|
Service Code
|
NDC 60687076727
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$86.49 |
| Rate for Payer: Cash Price |
$57.96
|
| Rate for Payer: Health Management Network Commercial |
$75.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.25
|
| Rate for Payer: MDX Hawaii PPO |
$86.49
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
NDC 00008084402
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.60 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
OP
|
$89.16
|
|
|
Service Code
|
NDC 27241025638
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.58 |
| Max. Negotiated Rate |
$86.49 |
| Rate for Payer: AlohaCare Medicaid |
$44.58
|
| Rate for Payer: AlohaCare Medicare |
$44.58
|
| Rate for Payer: Cash Price |
$57.95
|
| Rate for Payer: Devoted Health Medicare |
$49.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$84.70
|
| Rate for Payer: Health Management Network Commercial |
$75.79
|
| Rate for Payer: Humana Medicare |
$44.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.58
|
| Rate for Payer: MDX Hawaii PPO |
$86.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.58
|
| Rate for Payer: University Health Alliance Commercial |
$64.99
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
OP
|
$89.16
|
|
|
Service Code
|
NDC 62756007164
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.58 |
| Max. Negotiated Rate |
$86.49 |
| Rate for Payer: AlohaCare Medicaid |
$44.58
|
| Rate for Payer: AlohaCare Medicare |
$44.58
|
| Rate for Payer: Cash Price |
$57.95
|
| Rate for Payer: Devoted Health Medicare |
$49.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$84.70
|
| Rate for Payer: Health Management Network Commercial |
$75.79
|
| Rate for Payer: Humana Medicare |
$44.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.58
|
| Rate for Payer: MDX Hawaii PPO |
$86.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.58
|
| Rate for Payer: University Health Alliance Commercial |
$64.99
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
NDC 00008084402
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.00 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: AlohaCare Medicaid |
$38.00
|
| Rate for Payer: AlohaCare Medicare |
$38.00
|
| Rate for Payer: Cash Price |
$49.40
|
| Rate for Payer: Devoted Health Medicare |
$41.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.20
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Humana Medicare |
$38.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.00
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.00
|
| Rate for Payer: University Health Alliance Commercial |
$55.40
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
OP
|
$89.17
|
|
|
Service Code
|
NDC 60687076727
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.59 |
| Max. Negotiated Rate |
$86.49 |
| Rate for Payer: AlohaCare Medicaid |
$44.59
|
| Rate for Payer: AlohaCare Medicare |
$44.59
|
| Rate for Payer: Cash Price |
$57.96
|
| Rate for Payer: Devoted Health Medicare |
$49.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$84.71
|
| Rate for Payer: Health Management Network Commercial |
$75.79
|
| Rate for Payer: Humana Medicare |
$44.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.59
|
| Rate for Payer: MDX Hawaii PPO |
$86.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.59
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.59
|
| Rate for Payer: University Health Alliance Commercial |
$65.00
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
IP
|
$89.16
|
|
|
Service Code
|
NDC 62756007164
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$86.49 |
| Rate for Payer: Cash Price |
$57.95
|
| Rate for Payer: Health Management Network Commercial |
$75.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.24
|
| Rate for Payer: MDX Hawaii PPO |
$86.49
|
|
|
pantoprazole 40 mg packet [HHSC]
|
Facility
|
IP
|
$89.16
|
|
|
Service Code
|
NDC 27241025638
|
| Hospital Charge Code |
2500635
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.79 |
| Max. Negotiated Rate |
$86.49 |
| Rate for Payer: Cash Price |
$57.95
|
| Rate for Payer: Health Management Network Commercial |
$75.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.24
|
| Rate for Payer: MDX Hawaii PPO |
$86.49
|
|
|
pantoprazole 40mg vial [HHSC]
|
Facility
|
IP
|
$32.56
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
2500633
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.68 |
| Max. Negotiated Rate |
$31.58 |
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$33.20
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Health Management Network Commercial |
$16.85
|
| Rate for Payer: Health Management Network Commercial |
$19.28
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Health Management Network Commercial |
$27.68
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$40.52
|
| Rate for Payer: Health Management Network Commercial |
$43.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: MDX Hawaii PPO |
$22.00
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$19.23
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$31.58
|
| Rate for Payer: MDX Hawaii PPO |
$49.55
|
| Rate for Payer: MDX Hawaii PPO |
$46.24
|
|
|
pantoprazole 40mg vial [HHSC]
|
Facility
|
OP
|
$22.68
|
|
|
Service Code
|
HCPCS J2470
|
| Hospital Charge Code |
2500633
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.34 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: AlohaCare Medicaid |
$11.34
|
| Rate for Payer: AlohaCare Medicaid |
$25.54
|
| Rate for Payer: AlohaCare Medicaid |
$16.28
|
| Rate for Payer: AlohaCare Medicaid |
$9.91
|
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicaid |
$23.84
|
| Rate for Payer: AlohaCare Medicaid |
$11.68
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: AlohaCare Medicare |
$23.84
|
| Rate for Payer: AlohaCare Medicare |
$11.34
|
| Rate for Payer: AlohaCare Medicare |
$25.54
|
| Rate for Payer: AlohaCare Medicare |
$9.91
|
| Rate for Payer: AlohaCare Medicare |
$11.68
|
| Rate for Payer: AlohaCare Medicare |
$16.28
|
| Rate for Payer: Cash Price |
$33.20
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cash Price |
$12.88
|
| Rate for Payer: Cash Price |
$14.74
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Devoted Health Medicare |
$12.84
|
| Rate for Payer: Devoted Health Medicare |
$10.90
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Devoted Health Medicare |
$17.91
|
| Rate for Payer: Devoted Health Medicare |
$12.47
|
| Rate for Payer: Devoted Health Medicare |
$28.09
|
| Rate for Payer: Devoted Health Medicare |
$26.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.53
|
| Rate for Payer: Health Management Network Commercial |
$16.85
|
| Rate for Payer: Health Management Network Commercial |
$19.28
|
| Rate for Payer: Health Management Network Commercial |
$19.85
|
| Rate for Payer: Health Management Network Commercial |
$27.68
|
| Rate for Payer: Health Management Network Commercial |
$40.52
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Health Management Network Commercial |
$43.42
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Humana Medicare |
$11.68
|
| Rate for Payer: Humana Medicare |
$25.54
|
| Rate for Payer: Humana Medicare |
$11.34
|
| Rate for Payer: Humana Medicare |
$9.91
|
| Rate for Payer: Humana Medicare |
$23.84
|
| Rate for Payer: Humana Medicare |
$16.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.84
|
| Rate for Payer: MDX Hawaii PPO |
$46.24
|
| Rate for Payer: MDX Hawaii PPO |
$22.65
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: MDX Hawaii PPO |
$49.55
|
| Rate for Payer: MDX Hawaii PPO |
$19.23
|
| Rate for Payer: MDX Hawaii PPO |
$22.00
|
| Rate for Payer: MDX Hawaii PPO |
$31.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.28
|
| Rate for Payer: University Health Alliance Commercial |
$37.23
|
| Rate for Payer: University Health Alliance Commercial |
$17.02
|
| Rate for Payer: University Health Alliance Commercial |
$34.75
|
| Rate for Payer: University Health Alliance Commercial |
$16.53
|
| Rate for Payer: University Health Alliance Commercial |
$23.73
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
| Rate for Payer: University Health Alliance Commercial |
$14.45
|
|
|
pantoprazole DR 40 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687073665
|
| Hospital Charge Code |
2500634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
pantoprazole DR 40 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687073609
|
| Hospital Charge Code |
2500634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
pantoprazole DR 40 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 66993006880
|
| Hospital Charge Code |
2500634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
pantoprazole DR 40 mg tablet [HHSC]
|
Facility
|
IP
|
$22.39
|
|
|
Service Code
|
NDC 50268063915
|
| Hospital Charge Code |
2500634
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.03 |
| Max. Negotiated Rate |
$21.72 |
| Rate for Payer: Cash Price |
$14.55
|
| Rate for Payer: Health Management Network Commercial |
$19.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.15
|
| Rate for Payer: MDX Hawaii PPO |
$21.72
|
|
