|
PROPRANOLOL 20 MG TABLET [6657]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687059801
|
|
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 20 MG TABLET [6657]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687059811
|
|
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
|
|
|
PR OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF
|
Professional
|
Both
|
$1,161.00
|
|
|
Service Code
|
HCPCS 23552
|
| Min. Negotiated Rate |
$478.14 |
| Max. Negotiated Rate |
$986.85 |
| Rate for Payer: AlohaCare Medicaid |
$679.70
|
| Rate for Payer: AlohaCare Medicare |
$625.26
|
| Rate for Payer: Cash Price |
$696.60
|
| Rate for Payer: Cash Price |
$696.60
|
| Rate for Payer: Devoted Health Medicare |
$687.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$625.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$478.14
|
| Rate for Payer: Health Management Network Commercial |
$986.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$750.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$750.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$750.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$679.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$625.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$679.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$625.26
|
|
|
PR OPTX ANKLE DISLOCATION W/REPAIR/INT/XTRNL FIXJ
|
Professional
|
Both
|
$1,410.00
|
|
|
Service Code
|
HCPCS 27848
|
| Min. Negotiated Rate |
$729.56 |
| Max. Negotiated Rate |
$1,198.50 |
| Rate for Payer: AlohaCare Medicaid |
$815.47
|
| Rate for Payer: AlohaCare Medicare |
$746.72
|
| Rate for Payer: Cash Price |
$846.00
|
| Rate for Payer: Cash Price |
$846.00
|
| Rate for Payer: Devoted Health Medicare |
$821.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$746.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$729.56
|
| Rate for Payer: Health Management Network Commercial |
$1,198.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$896.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$896.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$896.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$815.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$746.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$815.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$746.72
|
|
|
PR OPTX COMP MANDIBULAR FX MLT APPR W/INT FIXATION
|
Professional
|
Both
|
$2,064.00
|
|
|
Service Code
|
HCPCS 21470
|
| Min. Negotiated Rate |
$1,055.88 |
| Max. Negotiated Rate |
$1,754.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,204.31
|
| Rate for Payer: AlohaCare Medicare |
$1,055.88
|
| Rate for Payer: Cash Price |
$1,238.40
|
| Rate for Payer: Cash Price |
$1,238.40
|
| Rate for Payer: Devoted Health Medicare |
$1,161.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,055.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,219.92
|
| Rate for Payer: Health Management Network Commercial |
$1,754.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,267.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,267.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,267.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,204.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,055.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,204.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,055.88
|
|
|
PR OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG
|
Professional
|
Both
|
$1,492.00
|
|
|
Service Code
|
HCPCS 25608
|
| Min. Negotiated Rate |
$705.12 |
| Max. Negotiated Rate |
$1,268.20 |
| Rate for Payer: AlohaCare Medicaid |
$867.41
|
| Rate for Payer: AlohaCare Medicare |
$787.83
|
| Rate for Payer: Cash Price |
$895.20
|
| Rate for Payer: Cash Price |
$895.20
|
| Rate for Payer: Devoted Health Medicare |
$866.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$787.83
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$705.12
|
| Rate for Payer: Health Management Network Commercial |
$1,268.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$945.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$945.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$945.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$867.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$787.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$867.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$787.83
|
|
|
PR OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3+ FRAG
|
Professional
|
Both
|
$1,886.00
|
|
|
Service Code
|
HCPCS 25609
|
| Min. Negotiated Rate |
$897.52 |
| Max. Negotiated Rate |
$1,603.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,095.88
|
| Rate for Payer: AlohaCare Medicare |
$985.54
|
| Rate for Payer: Cash Price |
$1,131.60
|
| Rate for Payer: Cash Price |
$1,131.60
|
| Rate for Payer: Devoted Health Medicare |
$1,084.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$985.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$897.52
|
| Rate for Payer: Health Management Network Commercial |
$1,603.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,182.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,182.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,182.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,095.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$985.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,095.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$985.54
|
|
|
PR OPTX DSTL RDL X-ARTIC FX/EPIPHYSL SEPARATION
|
Professional
|
Both
|
$1,344.00
|
|
|
Service Code
|
HCPCS 25607
|
| Min. Negotiated Rate |
$615.68 |
| Max. Negotiated Rate |
$1,142.40 |
| Rate for Payer: AlohaCare Medicaid |
$780.37
|
| Rate for Payer: AlohaCare Medicare |
$715.27
|
| Rate for Payer: Cash Price |
$806.40
|
| Rate for Payer: Cash Price |
$806.40
|
| Rate for Payer: Devoted Health Medicare |
$786.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$715.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$615.68
|
| Rate for Payer: Health Management Network Commercial |
$1,142.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$858.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$858.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$858.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$780.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$715.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$780.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$715.27
|
|
|
PR OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT
|
Professional
|
Both
|
$2,091.00
|
|
|
Service Code
|
HCPCS 27236
|
| Min. Negotiated Rate |
$971.62 |
| Max. Negotiated Rate |
$1,777.35 |
| Rate for Payer: AlohaCare Medicaid |
$1,218.72
|
| Rate for Payer: AlohaCare Medicare |
$1,093.33
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Cash Price |
$1,254.60
|
| Rate for Payer: Devoted Health Medicare |
$1,202.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,093.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$971.62
|
| Rate for Payer: Health Management Network Commercial |
$1,777.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,312.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,312.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,312.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,218.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,093.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,218.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,093.33
|
|
|
PR OPTX FEM SHFT FX W/INSJ IMED IMPLT W/WO SCREW
|
Professional
|
Both
|
$2,346.00
|
|
|
Service Code
|
HCPCS 27506
|
| Min. Negotiated Rate |
$1,227.93 |
| Max. Negotiated Rate |
$1,994.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,366.75
|
| Rate for Payer: AlohaCare Medicare |
$1,227.93
|
| Rate for Payer: Cash Price |
$1,407.60
|
| Rate for Payer: Cash Price |
$1,407.60
|
| Rate for Payer: Devoted Health Medicare |
$1,350.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,227.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,306.24
|
| Rate for Payer: Health Management Network Commercial |
$1,994.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,473.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,473.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,473.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,366.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,227.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,366.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,227.93
|
|
|
PR OPTX FEM SHFT FX W/PLATE/SCREWS W/WO CERCLAGE
|
Professional
|
Both
|
$1,694.00
|
|
|
Service Code
|
HCPCS 27507
|
| Min. Negotiated Rate |
$876.72 |
| Max. Negotiated Rate |
$1,439.90 |
| Rate for Payer: AlohaCare Medicaid |
$985.73
|
| Rate for Payer: AlohaCare Medicare |
$884.15
|
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Cash Price |
$1,016.40
|
| Rate for Payer: Devoted Health Medicare |
$972.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$884.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$876.72
|
| Rate for Payer: Health Management Network Commercial |
$1,439.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,060.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,060.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,060.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$985.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$884.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$985.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$884.15
|
|
|
PR OPTX GREATER HUMERAL TUBEROSITY FX W/INT FIXJ
|
Professional
|
Both
|
$1,400.00
|
|
|
Service Code
|
HCPCS 23630
|
| Min. Negotiated Rate |
$469.82 |
| Max. Negotiated Rate |
$1,190.00 |
| Rate for Payer: AlohaCare Medicaid |
$814.84
|
| Rate for Payer: AlohaCare Medicare |
$748.23
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Devoted Health Medicare |
$823.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$748.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$469.82
|
| Rate for Payer: Health Management Network Commercial |
$1,190.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$897.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$897.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$897.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$814.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$748.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$814.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$748.23
|
|
|
PR OPTX HUMERAL SHFT FX W/PLATE/SCREWS W/WOCERCLAGE
|
Professional
|
Both
|
$1,570.00
|
|
|
Service Code
|
HCPCS 24515
|
| Min. Negotiated Rate |
$641.68 |
| Max. Negotiated Rate |
$1,334.50 |
| Rate for Payer: AlohaCare Medicaid |
$914.10
|
| Rate for Payer: AlohaCare Medicare |
$834.87
|
| Rate for Payer: Cash Price |
$942.00
|
| Rate for Payer: Cash Price |
$942.00
|
| Rate for Payer: Devoted Health Medicare |
$918.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$834.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$641.68
|
| Rate for Payer: Health Management Network Commercial |
$1,334.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,001.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,001.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,001.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$914.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$834.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$914.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$834.87
|
|
|
PR OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC
|
Professional
|
Both
|
$1,426.00
|
|
|
Service Code
|
HCPCS 21390
|
| Min. Negotiated Rate |
$727.98 |
| Max. Negotiated Rate |
$1,212.10 |
| Rate for Payer: AlohaCare Medicaid |
$837.84
|
| Rate for Payer: AlohaCare Medicare |
$727.98
|
| Rate for Payer: Cash Price |
$855.60
|
| Rate for Payer: Cash Price |
$855.60
|
| Rate for Payer: Devoted Health Medicare |
$800.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$727.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$853.32
|
| Rate for Payer: Health Management Network Commercial |
$1,212.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$873.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$873.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$873.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$837.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$727.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$837.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$727.98
|
|
|
PR OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR
|
Professional
|
Both
|
$1,344.00
|
|
|
Service Code
|
HCPCS 27524
|
| Min. Negotiated Rate |
$607.62 |
| Max. Negotiated Rate |
$1,142.40 |
| Rate for Payer: AlohaCare Medicaid |
$782.75
|
| Rate for Payer: AlohaCare Medicare |
$716.10
|
| Rate for Payer: Cash Price |
$806.40
|
| Rate for Payer: Cash Price |
$806.40
|
| Rate for Payer: Devoted Health Medicare |
$787.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$716.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$607.62
|
| Rate for Payer: Health Management Network Commercial |
$1,142.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$859.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$859.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$859.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$782.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$716.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$782.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$716.10
|
|
|
PR OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBO
|
Professional
|
Both
|
$1,910.00
|
|
|
Service Code
|
HCPCS 24586
|
| Min. Negotiated Rate |
$995.93 |
| Max. Negotiated Rate |
$1,623.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,115.54
|
| Rate for Payer: AlohaCare Medicare |
$995.93
|
| Rate for Payer: Cash Price |
$1,146.00
|
| Rate for Payer: Cash Price |
$1,146.00
|
| Rate for Payer: Devoted Health Medicare |
$1,095.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$995.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,153.62
|
| Rate for Payer: Health Management Network Commercial |
$1,623.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,195.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,195.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,195.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,115.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$995.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,115.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$995.93
|
|
|
PR OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHR
|
Professional
|
Both
|
$1,915.00
|
|
|
Service Code
|
HCPCS 24587
|
| Min. Negotiated Rate |
$847.34 |
| Max. Negotiated Rate |
$1,627.75 |
| Rate for Payer: AlohaCare Medicaid |
$1,116.02
|
| Rate for Payer: AlohaCare Medicare |
$1,004.85
|
| Rate for Payer: Cash Price |
$1,149.00
|
| Rate for Payer: Cash Price |
$1,149.00
|
| Rate for Payer: Devoted Health Medicare |
$1,105.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,004.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$847.34
|
| Rate for Payer: Health Management Network Commercial |
$1,627.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,205.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,205.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,205.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,116.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,004.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,116.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,004.85
|
|
|
PR OPTX PROX HUMERAL FX W/INT FIXJ RPR TUBEROSITY
|
Professional
|
Both
|
$1,572.00
|
|
|
Service Code
|
HCPCS 23615
|
| Min. Negotiated Rate |
$596.96 |
| Max. Negotiated Rate |
$1,336.20 |
| Rate for Payer: AlohaCare Medicaid |
$915.29
|
| Rate for Payer: AlohaCare Medicare |
$835.24
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Devoted Health Medicare |
$918.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$835.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$596.96
|
| Rate for Payer: Health Management Network Commercial |
$1,336.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,002.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,002.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,002.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$915.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$835.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$915.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$835.24
|
|
|
PR OPTX RADIAL&ULNAR SHFT FX W/INT FIXJ RADIUS&ULNA
|
Professional
|
Both
|
$1,619.00
|
|
|
Service Code
|
HCPCS 25575
|
| Min. Negotiated Rate |
$835.12 |
| Max. Negotiated Rate |
$1,376.15 |
| Rate for Payer: AlohaCare Medicaid |
$941.93
|
| Rate for Payer: AlohaCare Medicare |
$860.53
|
| Rate for Payer: Cash Price |
$971.40
|
| Rate for Payer: Cash Price |
$971.40
|
| Rate for Payer: Devoted Health Medicare |
$946.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$860.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$835.12
|
| Rate for Payer: Health Management Network Commercial |
$1,376.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,032.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,032.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,032.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$941.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$860.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$941.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$860.53
|
|
|
PR OPTX RDL SHAFT FX&CLTX DSTL RAD/ULN JT DISLC
|
Professional
|
Both
|
$1,421.00
|
|
|
Service Code
|
HCPCS 25525
|
| Min. Negotiated Rate |
$703.04 |
| Max. Negotiated Rate |
$1,207.85 |
| Rate for Payer: AlohaCare Medicaid |
$827.57
|
| Rate for Payer: AlohaCare Medicare |
$752.29
|
| Rate for Payer: Cash Price |
$852.60
|
| Rate for Payer: Cash Price |
$852.60
|
| Rate for Payer: Devoted Health Medicare |
$827.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$752.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$703.04
|
| Rate for Payer: Health Management Network Commercial |
$1,207.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$902.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$902.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$902.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$827.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$752.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$827.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$752.29
|
|
|
PR OPTX TIBIAL FX PROX BICONDYLAR W/WO INT FIXJ
|
Professional
|
Both
|
$2,086.00
|
|
|
Service Code
|
HCPCS 27536
|
| Min. Negotiated Rate |
$814.58 |
| Max. Negotiated Rate |
$1,773.10 |
| Rate for Payer: AlohaCare Medicaid |
$1,214.66
|
| Rate for Payer: AlohaCare Medicare |
$1,095.62
|
| Rate for Payer: Cash Price |
$1,251.60
|
| Rate for Payer: Cash Price |
$1,251.60
|
| Rate for Payer: Devoted Health Medicare |
$1,205.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,095.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$814.58
|
| Rate for Payer: Health Management Network Commercial |
$1,773.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,314.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,314.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,314.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,214.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,095.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,214.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,095.62
|
|
|
PR OPTX TIBIAL SHFT FX W/PLATE/SCREWS W/WO CERCLAGE
|
Professional
|
Both
|
$1,592.00
|
|
|
Service Code
|
HCPCS 27758
|
| Min. Negotiated Rate |
$501.54 |
| Max. Negotiated Rate |
$1,353.20 |
| Rate for Payer: AlohaCare Medicaid |
$926.88
|
| Rate for Payer: AlohaCare Medicare |
$843.66
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Cash Price |
$955.20
|
| Rate for Payer: Devoted Health Medicare |
$928.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$843.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$501.54
|
| Rate for Payer: Health Management Network Commercial |
$1,353.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,012.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,012.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,012.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$926.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$843.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$926.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$843.66
|
|
|
PROPYLTHIOURACIL 50 MG TABLET [6662]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 00480924201
|
|
Hospital Revenue Code
|
637
|
| 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: University Health Alliance Commercial |
$2.92
|
|
|
PROPYLTHIOURACIL 50 MG TABLET [6662]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 00480924201
|
|
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
|
|
|
PROPYLTHIOURACIL 50 MG TABLET [6662]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 67253065110
|
|
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
|
|
