|
PROBE PRASS NERVE LOCATE
|
Facility
|
IP
|
$953.00
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$810.05 |
| Max. Negotiated Rate |
$924.41 |
| Rate for Payer: Cash Price |
$571.80
|
| Rate for Payer: Health Management Network Commercial |
$810.05
|
| Rate for Payer: MDX Hawaii PPO |
$924.41
|
|
|
PR OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE
|
Professional
|
Both
|
$1,410.13
|
|
|
Service Code
|
HCPCS 49460
|
| Min. Negotiated Rate |
$42.07 |
| Max. Negotiated Rate |
$1,198.61 |
| Rate for Payer: AlohaCare Medicaid |
$49.68
|
| Rate for Payer: AlohaCare Medicare |
$42.07
|
| Rate for Payer: Cash Price |
$846.08
|
| Rate for Payer: Cash Price |
$846.08
|
| Rate for Payer: Devoted Health Medicare |
$46.28
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$49.68
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$80.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.07
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$49.68
|
| Rate for Payer: Health Management Network Commercial |
$1,198.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$50.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$42.07
|
| Rate for Payer: University Health Alliance Commercial |
$63.46
|
|
|
PR OBTAINING SCREEN PAP SMEAR
|
Professional
|
Both
|
$87.85
|
|
|
Service Code
|
HCPCS Q0091
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$74.67 |
| Rate for Payer: AlohaCare Medicare |
$15.64
|
| Rate for Payer: Cash Price |
$52.71
|
| Rate for Payer: Cash Price |
$52.71
|
| Rate for Payer: Devoted Health Medicare |
$17.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.00
|
| Rate for Payer: Health Management Network Commercial |
$74.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$18.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.64
|
| Rate for Payer: University Health Alliance Commercial |
$17.91
|
|
|
PR OCCLUSIVE DEVICE IN VEIN ART
|
Professional
|
Both
|
$342.00
|
|
|
Service Code
|
HCPCS G0269
|
| Min. Negotiated Rate |
$290.70 |
| Max. Negotiated Rate |
$290.70 |
| Rate for Payer: Cash Price |
$205.20
|
| Rate for Payer: Health Management Network Commercial |
$290.70
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$10,354.90
|
|
|
Service Code
|
APR-DRG 4033
|
| Min. Negotiated Rate |
$10,354.90 |
| Max. Negotiated Rate |
$10,354.90 |
| Rate for Payer: AlohaCare Medicaid |
$10,354.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10,354.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10,354.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,354.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,354.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10,354.90
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$25,710.80
|
|
|
Service Code
|
APR-DRG 4034
|
| Min. Negotiated Rate |
$25,710.80 |
| Max. Negotiated Rate |
$25,710.80 |
| Rate for Payer: AlohaCare Medicaid |
$25,710.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$25,710.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$25,710.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25,710.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25,710.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25,710.80
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$6,642.79
|
|
|
Service Code
|
APR-DRG 4031
|
| Min. Negotiated Rate |
$6,642.79 |
| Max. Negotiated Rate |
$6,642.79 |
| Rate for Payer: AlohaCare Medicaid |
$6,642.79
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6,642.79
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6,642.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,642.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,642.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,642.79
|
|
|
PROCEDURES FOR OBESITY
|
Facility
|
IP
|
$7,537.06
|
|
|
Service Code
|
APR-DRG 4032
|
| Min. Negotiated Rate |
$7,537.06 |
| Max. Negotiated Rate |
$7,537.06 |
| Rate for Payer: AlohaCare Medicaid |
$7,537.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7,537.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7,537.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7,537.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,537.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,537.06
|
|
|
PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE
|
Facility
|
IP
|
$29,152.22
|
|
|
Service Code
|
APR-DRG 8504
|
| Min. Negotiated Rate |
$29,152.22 |
| Max. Negotiated Rate |
$29,152.22 |
| Rate for Payer: AlohaCare Medicaid |
$29,152.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$29,152.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$29,152.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29,152.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$29,152.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29,152.22
|
|
|
PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE
|
Facility
|
IP
|
$11,007.83
|
|
|
Service Code
|
APR-DRG 8502
|
| Min. Negotiated Rate |
$11,007.83 |
| Max. Negotiated Rate |
$11,007.83 |
| Rate for Payer: AlohaCare Medicaid |
$11,007.83
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$11,007.83
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$11,007.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11,007.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,007.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11,007.83
|
|
|
PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE
|
Facility
|
IP
|
$13,645.63
|
|
|
Service Code
|
APR-DRG 8503
|
| Min. Negotiated Rate |
$13,645.63 |
| Max. Negotiated Rate |
$13,645.63 |
| Rate for Payer: AlohaCare Medicaid |
$13,645.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$13,645.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13,645.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13,645.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13,645.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13,645.63
|
|
|
PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE
|
Facility
|
IP
|
$8,908.80
|
|
|
Service Code
|
APR-DRG 8501
|
| Min. Negotiated Rate |
$8,908.80 |
| Max. Negotiated Rate |
$8,908.80 |
| Rate for Payer: AlohaCare Medicaid |
$8,908.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8,908.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8,908.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,908.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,908.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8,908.80
|
|
|
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 00574722612
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
|
|
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 00713013506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 00574722612
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$31.04 |
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
|
|
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00713013506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
NDC 00713013512
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.81 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.45
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
| Rate for Payer: University Health Alliance Commercial |
$22.60
|
|
|
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY [11138]
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
NDC 00713013512
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.35 |
| Max. Negotiated Rate |
$30.07 |
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Health Management Network Commercial |
$26.35
|
| Rate for Payer: MDX Hawaii PPO |
$30.07
|
|
|
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [166223]
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS J0780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.55 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
|
|
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION [166223]
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS J0780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Health Management Network Commercial |
$19.55
|
| Rate for Payer: Health Management Network Commercial |
$20.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$14.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.24
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$23.28
|
| Rate for Payer: MDX Hawaii PPO |
$22.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.00
|
| Rate for Payer: University Health Alliance Commercial |
$17.49
|
| Rate for Payer: University Health Alliance Commercial |
$16.76
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
PROCHLORPERAZINE MALEATE 10 MG TABLET [6582]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS Q0164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
PROCHLORPERAZINE MALEATE 10 MG TABLET [6582]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS Q0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS Q0164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS Q0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES
|
Professional
|
Both
|
$379.00
|
|
|
Service Code
|
HCPCS 99245
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$150.80 |
| Max. Negotiated Rate |
$322.15 |
| Rate for Payer: Cash Price |
$227.40
|
| Rate for Payer: Cash Price |
$227.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$181.90
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$181.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$150.80
|
| Rate for Payer: Health Management Network Commercial |
$322.15
|
|
