|
PR OPEN TX METACARPAL FRACTURE SINGLE EA BONE
|
Professional
|
Both
|
$1,055.00
|
|
|
Service Code
|
HCPCS 26615
|
| Min. Negotiated Rate |
$421.46 |
| Max. Negotiated Rate |
$896.75 |
| Rate for Payer: AlohaCare Medicaid |
$612.81
|
| Rate for Payer: AlohaCare Medicare |
$566.50
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Cash Price |
$633.00
|
| Rate for Payer: Devoted Health Medicare |
$623.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$566.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$421.46
|
| Rate for Payer: Health Management Network Commercial |
$896.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$679.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$679.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$679.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$612.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$566.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$612.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$566.50
|
|
|
PR OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW
|
Professional
|
Both
|
$1,226.00
|
|
|
Service Code
|
HCPCS 24635
|
| Min. Negotiated Rate |
$655.94 |
| Max. Negotiated Rate |
$1,042.10 |
| Rate for Payer: AlohaCare Medicaid |
$710.57
|
| Rate for Payer: AlohaCare Medicare |
$655.94
|
| Rate for Payer: Cash Price |
$735.60
|
| Rate for Payer: Cash Price |
$735.60
|
| Rate for Payer: Devoted Health Medicare |
$721.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$655.94
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$795.08
|
| Rate for Payer: Health Management Network Commercial |
$1,042.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$787.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$787.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$787.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$710.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$655.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$710.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$655.94
|
|
|
PR OPEN TX PALATAL/MAXILLARY FX COMP MULTIPLE APPR
|
Professional
|
Both
|
$1,409.00
|
|
|
Service Code
|
HCPCS 21423
|
| Min. Negotiated Rate |
$600.86 |
| Max. Negotiated Rate |
$1,197.65 |
| Rate for Payer: AlohaCare Medicaid |
$822.87
|
| Rate for Payer: AlohaCare Medicare |
$735.74
|
| Rate for Payer: Cash Price |
$845.40
|
| Rate for Payer: Cash Price |
$845.40
|
| Rate for Payer: Devoted Health Medicare |
$809.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$735.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$600.86
|
| Rate for Payer: Health Management Network Commercial |
$1,197.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$882.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$882.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$882.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$822.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$735.74
|
| Rate for Payer: UnitedHealthcare Medicaid |
$822.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$735.74
|
|
|
PR OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA
|
Professional
|
Both
|
$1,087.00
|
|
|
Service Code
|
HCPCS 26735
|
| Min. Negotiated Rate |
$402.74 |
| Max. Negotiated Rate |
$923.95 |
| Rate for Payer: AlohaCare Medicaid |
$632.08
|
| Rate for Payer: AlohaCare Medicare |
$582.63
|
| Rate for Payer: Cash Price |
$652.20
|
| Rate for Payer: Cash Price |
$652.20
|
| Rate for Payer: Devoted Health Medicare |
$640.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$582.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$402.74
|
| Rate for Payer: Health Management Network Commercial |
$923.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$699.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$699.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$699.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$632.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$582.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$632.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$582.63
|
|
|
PR OPEN TX RADIAL HEAD/NECK FRACTURE
|
Professional
|
Both
|
$1,195.00
|
|
|
Service Code
|
HCPCS 24665
|
| Min. Negotiated Rate |
$468.26 |
| Max. Negotiated Rate |
$1,015.75 |
| Rate for Payer: AlohaCare Medicaid |
$694.44
|
| Rate for Payer: AlohaCare Medicare |
$639.65
|
| Rate for Payer: Cash Price |
$717.00
|
| Rate for Payer: Cash Price |
$717.00
|
| Rate for Payer: Devoted Health Medicare |
$703.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$639.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$468.26
|
| Rate for Payer: Health Management Network Commercial |
$1,015.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$767.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$767.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$767.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$694.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$639.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$694.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$639.65
|
|
|
PR OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC
|
Professional
|
Both
|
$1,315.00
|
|
|
Service Code
|
HCPCS 24666
|
| Min. Negotiated Rate |
$596.44 |
| Max. Negotiated Rate |
$1,117.75 |
| Rate for Payer: AlohaCare Medicaid |
$765.27
|
| Rate for Payer: AlohaCare Medicare |
$698.59
|
| Rate for Payer: Cash Price |
$789.00
|
| Rate for Payer: Cash Price |
$789.00
|
| Rate for Payer: Devoted Health Medicare |
$768.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$698.59
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$596.44
|
| Rate for Payer: Health Management Network Commercial |
$1,117.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$838.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$838.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$838.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$765.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$698.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$765.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$698.59
|
|
|
PR OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1/> BONES
|
Professional
|
Both
|
$1,095.00
|
|
|
Service Code
|
HCPCS 25670
|
| Min. Negotiated Rate |
$459.42 |
| Max. Negotiated Rate |
$930.75 |
| Rate for Payer: AlohaCare Medicaid |
$638.62
|
| Rate for Payer: AlohaCare Medicare |
$592.24
|
| Rate for Payer: Cash Price |
$657.00
|
| Rate for Payer: Cash Price |
$657.00
|
| Rate for Payer: Devoted Health Medicare |
$651.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$592.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$459.42
|
| Rate for Payer: Health Management Network Commercial |
$930.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$710.69
|
| Rate for Payer: Kaiser Permanente Medicaid |
$710.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$710.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$638.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$592.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$638.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$592.24
|
|
|
PR OPEN TX SCAPULAR FX W/INT FIXATION WHEN PFRMD
|
Professional
|
Both
|
$1,721.00
|
|
|
Service Code
|
HCPCS 23585
|
| Min. Negotiated Rate |
$666.12 |
| Max. Negotiated Rate |
$1,462.85 |
| Rate for Payer: AlohaCare Medicaid |
$1,002.91
|
| Rate for Payer: AlohaCare Medicare |
$902.13
|
| Rate for Payer: Cash Price |
$1,032.60
|
| Rate for Payer: Cash Price |
$1,032.60
|
| Rate for Payer: Devoted Health Medicare |
$992.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$902.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$666.12
|
| Rate for Payer: Health Management Network Commercial |
$1,462.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,082.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,082.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,082.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,002.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$902.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,002.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$902.13
|
|
|
PR OPEN TX TARSAL FRACTURE XCP TALUS & CALCANEUS EA
|
Professional
|
Both
|
$1,163.00
|
|
|
Service Code
|
HCPCS 28465
|
| Min. Negotiated Rate |
$483.34 |
| Max. Negotiated Rate |
$988.55 |
| Rate for Payer: AlohaCare Medicaid |
$675.97
|
| Rate for Payer: AlohaCare Medicare |
$639.86
|
| Rate for Payer: Cash Price |
$697.80
|
| Rate for Payer: Cash Price |
$697.80
|
| Rate for Payer: Devoted Health Medicare |
$703.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$639.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$483.34
|
| Rate for Payer: Health Management Network Commercial |
$988.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$767.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$767.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$767.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$675.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$639.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$675.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$639.86
|
|
|
PR OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR
|
Professional
|
Both
|
$1,568.00
|
|
|
Service Code
|
HCPCS 27535
|
| Min. Negotiated Rate |
$815.95 |
| Max. Negotiated Rate |
$1,332.80 |
| Rate for Payer: AlohaCare Medicaid |
$914.07
|
| Rate for Payer: AlohaCare Medicare |
$815.95
|
| Rate for Payer: Cash Price |
$940.80
|
| Rate for Payer: Cash Price |
$940.80
|
| Rate for Payer: Devoted Health Medicare |
$897.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$815.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$929.50
|
| Rate for Payer: Health Management Network Commercial |
$1,332.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$979.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$979.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$979.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$914.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$815.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$914.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$815.95
|
|
|
PR OPEN TX TRIMALLEOLAR ANKLE FX W/FIXJ PST LIP
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS 27823
|
| Min. Negotiated Rate |
$921.18 |
| Max. Negotiated Rate |
$1,487.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,025.17
|
| Rate for Payer: AlohaCare Medicare |
$943.82
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: Devoted Health Medicare |
$1,038.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$943.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$921.18
|
| Rate for Payer: Health Management Network Commercial |
$1,487.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,132.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,132.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,132.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,025.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$943.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,025.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$943.82
|
|
|
PR OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP
|
Professional
|
Both
|
$1,561.00
|
|
|
Service Code
|
HCPCS 27822
|
| Min. Negotiated Rate |
$849.65 |
| Max. Negotiated Rate |
$1,326.85 |
| Rate for Payer: AlohaCare Medicaid |
$915.30
|
| Rate for Payer: AlohaCare Medicare |
$849.65
|
| Rate for Payer: Cash Price |
$936.60
|
| Rate for Payer: Cash Price |
$936.60
|
| Rate for Payer: Devoted Health Medicare |
$934.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$849.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,021.54
|
| Rate for Payer: Health Management Network Commercial |
$1,326.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,019.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,019.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,019.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$915.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$849.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$915.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$849.65
|
|
|
PR OPN FEM ART EXPOS DLVR EVASC PROSTH UNI
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS 34812
|
| Min. Negotiated Rate |
$172.57 |
| Max. Negotiated Rate |
$471.83 |
| Rate for Payer: AlohaCare Medicaid |
$189.22
|
| Rate for Payer: AlohaCare Medicare |
$172.57
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Devoted Health Medicare |
$189.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$172.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$357.50
|
| Rate for Payer: Health Management Network Commercial |
$273.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$207.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$207.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$189.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$172.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$189.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$172.57
|
| Rate for Payer: University Health Alliance Commercial |
$471.83
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [131626]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J2704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION [131626]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J2704
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
PROPOFOL INFUSION 10 MG/ML (WRAPPED) [40840026]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J2704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
PROPOFOL INFUSION 10 MG/ML (WRAPPED) [40840026]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J2704
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
PROPRANOLOL 10 MG TABLET [6656]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687058711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
PROPRANOLOL 10 MG TABLET [6656]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687058701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
PROPRANOLOL 10 MG TABLET [6656]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687058711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
PROPRANOLOL 10 MG TABLET [6656]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687058701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION [29335]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J1800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$33.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$21.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$25.51
|
|
|
PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION [29335]
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
HCPCS J1800
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$33.95 |
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Health Management Network Commercial |
$29.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$33.95
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
PROPRANOLOL 20 MG TABLET [6657]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687059801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
PROPRANOLOL 20 MG TABLET [6657]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687059811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
