|
ER FACILITY PROCEDURE, LEVEL 4
|
Facility
|
OP
|
$2,850.00
|
|
| Hospital Charge Code |
8301086
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,425.00
|
| Rate for Payer: AlohaCare Medicare |
$1,425.00
|
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Devoted Health Medicare |
$1,567.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,425.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,707.50
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Humana Medicare |
$1,425.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,425.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,425.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,425.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,425.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,077.36
|
|
|
ER FACILITY PROCEDURE, LEVEL 4
|
Facility
|
IP
|
$2,850.00
|
|
| Hospital Charge Code |
8301086
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,422.50 |
| Max. Negotiated Rate |
$2,764.50 |
| Rate for Payer: Cash Price |
$1,852.50
|
| Rate for Payer: Health Management Network Commercial |
$2,422.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,565.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,764.50
|
|
|
ER FACILITY PROCEDURE, LEVEL 5
|
Facility
|
OP
|
$6,850.00
|
|
| Hospital Charge Code |
8301087
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$6,644.50 |
| Rate for Payer: AlohaCare Medicaid |
$3,425.00
|
| Rate for Payer: AlohaCare Medicare |
$3,425.00
|
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Devoted Health Medicare |
$3,767.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,425.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,507.50
|
| Rate for Payer: Health Management Network Commercial |
$5,822.50
|
| Rate for Payer: Humana Medicare |
$3,425.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,165.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,425.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,644.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,425.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,425.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,425.00
|
| Rate for Payer: University Health Alliance Commercial |
$4,992.97
|
|
|
ER FACILITY PROCEDURE, LEVEL 5
|
Facility
|
IP
|
$6,850.00
|
|
| Hospital Charge Code |
8301087
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,822.50 |
| Max. Negotiated Rate |
$6,644.50 |
| Rate for Payer: Cash Price |
$4,452.50
|
| Rate for Payer: Health Management Network Commercial |
$5,822.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,165.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,644.50
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
IP
|
$96.36
|
|
|
Service Code
|
NDC 00574402435
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.91 |
| Max. Negotiated Rate |
$93.47 |
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Health Management Network Commercial |
$81.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: MDX Hawaii PPO |
$93.47
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
IP
|
$96.11
|
|
|
Service Code
|
NDC 17478007035
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.69 |
| Max. Negotiated Rate |
$93.23 |
| Rate for Payer: Cash Price |
$62.47
|
| Rate for Payer: Health Management Network Commercial |
$81.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.50
|
| Rate for Payer: MDX Hawaii PPO |
$93.23
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
OP
|
$97.57
|
|
|
Service Code
|
NDC 24208091055
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.78 |
| Max. Negotiated Rate |
$94.64 |
| Rate for Payer: AlohaCare Medicaid |
$48.78
|
| Rate for Payer: AlohaCare Medicare |
$48.78
|
| Rate for Payer: Cash Price |
$63.42
|
| Rate for Payer: Devoted Health Medicare |
$53.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$92.69
|
| Rate for Payer: Health Management Network Commercial |
$82.93
|
| Rate for Payer: Humana Medicare |
$48.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.78
|
| Rate for Payer: MDX Hawaii PPO |
$94.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.78
|
| Rate for Payer: University Health Alliance Commercial |
$71.12
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
OP
|
$96.36
|
|
|
Service Code
|
NDC 00574402435
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.18 |
| Max. Negotiated Rate |
$93.47 |
| Rate for Payer: AlohaCare Medicaid |
$48.18
|
| Rate for Payer: AlohaCare Medicare |
$48.18
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Devoted Health Medicare |
$53.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.54
|
| Rate for Payer: Health Management Network Commercial |
$81.91
|
| Rate for Payer: Humana Medicare |
$48.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.18
|
| Rate for Payer: MDX Hawaii PPO |
$93.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.18
|
| Rate for Payer: University Health Alliance Commercial |
$70.24
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
OP
|
$139.16
|
|
|
Service Code
|
NDC 72485067035
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$69.58 |
| Max. Negotiated Rate |
$134.99 |
| Rate for Payer: AlohaCare Medicaid |
$69.58
|
| Rate for Payer: AlohaCare Medicare |
$69.58
|
| Rate for Payer: Cash Price |
$90.45
|
| Rate for Payer: Devoted Health Medicare |
$76.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$69.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$132.20
|
| Rate for Payer: Health Management Network Commercial |
$118.29
|
| Rate for Payer: Humana Medicare |
$69.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$69.58
|
| Rate for Payer: MDX Hawaii PPO |
$134.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$69.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$69.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$83.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$69.58
|
| Rate for Payer: University Health Alliance Commercial |
$101.43
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
IP
|
$97.57
|
|
|
Service Code
|
NDC 24208091055
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.93 |
| Max. Negotiated Rate |
$94.64 |
| Rate for Payer: Cash Price |
$63.42
|
| Rate for Payer: Health Management Network Commercial |
$82.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.81
|
| Rate for Payer: MDX Hawaii PPO |
$94.64
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
IP
|
$139.16
|
|
|
Service Code
|
NDC 72485067035
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$118.29 |
| Max. Negotiated Rate |
$134.99 |
| Rate for Payer: Cash Price |
$90.45
|
| Rate for Payer: Health Management Network Commercial |
$118.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$125.24
|
| Rate for Payer: MDX Hawaii PPO |
$134.99
|
|
|
erythromycin 0.5% ophth oint 3.5gm [HHSC]
|
Facility
|
OP
|
$96.11
|
|
|
Service Code
|
NDC 17478007035
|
| Hospital Charge Code |
2500309
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.05 |
| Max. Negotiated Rate |
$93.23 |
| Rate for Payer: AlohaCare Medicaid |
$48.05
|
| Rate for Payer: AlohaCare Medicare |
$48.05
|
| Rate for Payer: Cash Price |
$62.47
|
| Rate for Payer: Devoted Health Medicare |
$52.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.30
|
| Rate for Payer: Health Management Network Commercial |
$81.69
|
| Rate for Payer: Humana Medicare |
$48.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.05
|
| Rate for Payer: MDX Hawaii PPO |
$93.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.05
|
| Rate for Payer: University Health Alliance Commercial |
$70.05
|
|
|
Erythropoietin (EPO) FSI
|
Facility
|
OP
|
$109.00
|
|
|
Service Code
|
HCPCS 82668
|
| Hospital Charge Code |
8404557
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.79 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: AlohaCare Medicaid |
$54.50
|
| Rate for Payer: AlohaCare Medicare |
$54.50
|
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Devoted Health Medicare |
$59.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$25.97
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.79
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Humana Medicare |
$54.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.50
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.50
|
| Rate for Payer: University Health Alliance Commercial |
$48.58
|
|
|
Erythropoietin (EPO) FSI
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
HCPCS 82668
|
| Hospital Charge Code |
8404557
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$92.65 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Cash Price |
$70.85
|
| Rate for Payer: Health Management Network Commercial |
$92.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$98.10
|
| Rate for Payer: MDX Hawaii PPO |
$105.73
|
|
|
escitalopram 10 mg tablet [HHSC]
|
Facility
|
IP
|
$24.02
|
|
|
Service Code
|
NDC 68084061701
|
| Hospital Charge Code |
2500310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.42 |
| Max. Negotiated Rate |
$23.30 |
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
|
|
escitalopram 10 mg tablet [HHSC]
|
Facility
|
OP
|
$24.36
|
|
|
Service Code
|
NDC 00904642661
|
| Hospital Charge Code |
2500310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.18 |
| Max. Negotiated Rate |
$23.63 |
| Rate for Payer: AlohaCare Medicaid |
$12.18
|
| Rate for Payer: AlohaCare Medicare |
$12.18
|
| Rate for Payer: Cash Price |
$15.83
|
| Rate for Payer: Devoted Health Medicare |
$13.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.14
|
| Rate for Payer: Health Management Network Commercial |
$20.71
|
| Rate for Payer: Humana Medicare |
$12.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.18
|
| Rate for Payer: MDX Hawaii PPO |
$23.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.18
|
| Rate for Payer: University Health Alliance Commercial |
$17.76
|
|
|
escitalopram 10 mg tablet [HHSC]
|
Facility
|
IP
|
$24.36
|
|
|
Service Code
|
NDC 00904642661
|
| Hospital Charge Code |
2500310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.71 |
| Max. Negotiated Rate |
$23.63 |
| Rate for Payer: Cash Price |
$15.83
|
| Rate for Payer: Health Management Network Commercial |
$20.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.92
|
| Rate for Payer: MDX Hawaii PPO |
$23.63
|
|
|
escitalopram 10 mg tablet [HHSC]
|
Facility
|
OP
|
$24.02
|
|
|
Service Code
|
NDC 68084061701
|
| Hospital Charge Code |
2500310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$23.30 |
| Rate for Payer: AlohaCare Medicaid |
$12.01
|
| Rate for Payer: AlohaCare Medicare |
$12.01
|
| Rate for Payer: Cash Price |
$15.61
|
| Rate for Payer: Devoted Health Medicare |
$13.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.82
|
| Rate for Payer: Health Management Network Commercial |
$20.42
|
| Rate for Payer: Humana Medicare |
$12.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.01
|
| Rate for Payer: MDX Hawaii PPO |
$23.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.01
|
| Rate for Payer: University Health Alliance Commercial |
$17.51
|
|
|
escitalopram 20 mg tablet [HHSC]
|
Facility
|
IP
|
$25.06
|
|
|
Service Code
|
NDC 68084061801
|
| Hospital Charge Code |
2501207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.30 |
| Max. Negotiated Rate |
$24.31 |
| Rate for Payer: Cash Price |
$16.29
|
| Rate for Payer: Health Management Network Commercial |
$21.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.55
|
| Rate for Payer: MDX Hawaii PPO |
$24.31
|
|
|
escitalopram 20 mg tablet [HHSC]
|
Facility
|
OP
|
$25.06
|
|
|
Service Code
|
NDC 68084061801
|
| Hospital Charge Code |
2501207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$24.31 |
| Rate for Payer: AlohaCare Medicaid |
$12.53
|
| Rate for Payer: AlohaCare Medicare |
$12.53
|
| Rate for Payer: Cash Price |
$16.29
|
| Rate for Payer: Devoted Health Medicare |
$13.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.81
|
| Rate for Payer: Health Management Network Commercial |
$21.30
|
| Rate for Payer: Humana Medicare |
$12.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.53
|
| Rate for Payer: MDX Hawaii PPO |
$24.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.53
|
| Rate for Payer: University Health Alliance Commercial |
$18.27
|
|
|
esmolol 100 mg/10mL vial [HHSC]
|
Facility
|
OP
|
$52.29
|
|
|
Service Code
|
NDC 67457018210
|
| Hospital Charge Code |
2500312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.14 |
| Max. Negotiated Rate |
$50.72 |
| Rate for Payer: AlohaCare Medicaid |
$26.14
|
| Rate for Payer: AlohaCare Medicare |
$26.14
|
| Rate for Payer: Cash Price |
$33.99
|
| Rate for Payer: Devoted Health Medicare |
$28.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.68
|
| Rate for Payer: Health Management Network Commercial |
$44.45
|
| Rate for Payer: Humana Medicare |
$26.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.14
|
| Rate for Payer: MDX Hawaii PPO |
$50.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.14
|
| Rate for Payer: University Health Alliance Commercial |
$38.11
|
|
|
esmolol 100 mg/10mL vial [HHSC]
|
Facility
|
IP
|
$52.29
|
|
|
Service Code
|
NDC 67457018210
|
| Hospital Charge Code |
2500312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.45 |
| Max. Negotiated Rate |
$50.72 |
| Rate for Payer: Cash Price |
$33.99
|
| Rate for Payer: Health Management Network Commercial |
$44.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.06
|
| Rate for Payer: MDX Hawaii PPO |
$50.72
|
|
|
esmolol 100 mg/10mL vial [HHSC]
|
Facility
|
OP
|
$52.54
|
|
|
Service Code
|
NDC 55150019410
|
| Hospital Charge Code |
2500312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.27 |
| Max. Negotiated Rate |
$50.96 |
| Rate for Payer: AlohaCare Medicaid |
$26.27
|
| Rate for Payer: AlohaCare Medicare |
$26.27
|
| Rate for Payer: Cash Price |
$34.15
|
| Rate for Payer: Devoted Health Medicare |
$28.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.91
|
| Rate for Payer: Health Management Network Commercial |
$44.66
|
| Rate for Payer: Humana Medicare |
$26.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.27
|
| Rate for Payer: MDX Hawaii PPO |
$50.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.27
|
| Rate for Payer: University Health Alliance Commercial |
$38.30
|
|
|
esmolol 100 mg/10mL vial [HHSC]
|
Facility
|
IP
|
$90.28
|
|
|
Service Code
|
NDC 63323065210
|
| Hospital Charge Code |
2500312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$76.74 |
| Max. Negotiated Rate |
$87.57 |
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Health Management Network Commercial |
$76.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.25
|
| Rate for Payer: MDX Hawaii PPO |
$87.57
|
|
|
esmolol 100 mg/10mL vial [HHSC]
|
Facility
|
OP
|
$90.28
|
|
|
Service Code
|
NDC 63323065210
|
| Hospital Charge Code |
2500312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.14 |
| Max. Negotiated Rate |
$87.57 |
| Rate for Payer: AlohaCare Medicaid |
$45.14
|
| Rate for Payer: AlohaCare Medicare |
$45.14
|
| Rate for Payer: Cash Price |
$58.68
|
| Rate for Payer: Devoted Health Medicare |
$49.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.77
|
| Rate for Payer: Health Management Network Commercial |
$76.74
|
| Rate for Payer: Humana Medicare |
$45.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.14
|
| Rate for Payer: MDX Hawaii PPO |
$87.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.14
|
| Rate for Payer: University Health Alliance Commercial |
$65.81
|
|
