|
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: Kaiser Permanente Commercial |
$3.60
|
| 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 |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.04
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Devoted Health Medicare |
$3.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.04
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS Q0164
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PROCHLORPERAZINE MALEATE 5 MG TABLET [6583]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS Q0164
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| 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 |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
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
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT LOW MDM 30 MINUTES
|
Professional
|
Both
|
$206.00
|
|
|
Service Code
|
HCPCS 99243
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$89.13 |
| Max. Negotiated Rate |
$175.10 |
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Cash Price |
$123.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$89.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$89.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.54
|
| Rate for Payer: Health Management Network Commercial |
$175.10
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES
|
Professional
|
Both
|
$293.00
|
|
|
Service Code
|
HCPCS 99244
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$136.13 |
| Max. Negotiated Rate |
$249.05 |
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$136.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$136.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$139.47
|
| Rate for Payer: Health Management Network Commercial |
$249.05
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
HCPCS 99242
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$56.76 |
| Max. Negotiated Rate |
$118.15 |
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Cash Price |
$83.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$56.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$56.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.11
|
| Rate for Payer: Health Management Network Commercial |
$118.15
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN
|
Professional
|
Both
|
$353.54
|
|
|
Service Code
|
HCPCS 99215
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$83.80 |
| Max. Negotiated Rate |
$300.51 |
| Rate for Payer: AlohaCare Medicaid |
$145.89
|
| Rate for Payer: AlohaCare Medicare |
$126.07
|
| Rate for Payer: Cash Price |
$212.12
|
| Rate for Payer: Cash Price |
$212.12
|
| Rate for Payer: Devoted Health Medicare |
$138.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$145.89
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$145.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.80
|
| Rate for Payer: Health Management Network Commercial |
$300.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$151.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$145.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$126.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$145.89
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
Both
|
$176.07
|
|
|
Service Code
|
HCPCS 99213
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$42.37 |
| Max. Negotiated Rate |
$149.66 |
| Rate for Payer: AlohaCare Medicaid |
$66.56
|
| Rate for Payer: AlohaCare Medicare |
$57.69
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Cash Price |
$105.64
|
| Rate for Payer: Devoted Health Medicare |
$63.46
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$66.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$66.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.37
|
| Rate for Payer: Health Management Network Commercial |
$149.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$69.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.56
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$249.88
|
|
|
Service Code
|
HCPCS 99214
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$63.45 |
| Max. Negotiated Rate |
$212.40 |
| Rate for Payer: AlohaCare Medicaid |
$98.27
|
| Rate for Payer: AlohaCare Medicare |
$84.69
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: Cash Price |
$149.93
|
| Rate for Payer: Devoted Health Medicare |
$93.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$98.27
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$98.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.45
|
| Rate for Payer: Health Management Network Commercial |
$212.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.27
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$110.74
|
|
|
Service Code
|
HCPCS 99212
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$29.59 |
| Max. Negotiated Rate |
$94.13 |
| Rate for Payer: AlohaCare Medicaid |
$35.51
|
| Rate for Payer: AlohaCare Medicare |
$31.00
|
| Rate for Payer: Cash Price |
$66.44
|
| Rate for Payer: Cash Price |
$66.44
|
| Rate for Payer: Devoted Health Medicare |
$34.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$35.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$35.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.59
|
| Rate for Payer: Health Management Network Commercial |
$94.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$35.51
|
|
|
PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$46.74
|
|
|
Service Code
|
HCPCS 99211
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$39.73 |
| Rate for Payer: AlohaCare Medicaid |
$8.86
|
| Rate for Payer: AlohaCare Medicare |
$7.72
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Cash Price |
$28.04
|
| Rate for Payer: Devoted Health Medicare |
$8.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.23
|
| Rate for Payer: Health Management Network Commercial |
$39.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.86
|
|
|
PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$431.43
|
|
|
Service Code
|
HCPCS 99205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$135.52 |
| Max. Negotiated Rate |
$366.72 |
| Rate for Payer: AlohaCare Medicaid |
$182.72
|
| Rate for Payer: AlohaCare Medicare |
$159.56
|
| Rate for Payer: Cash Price |
$258.86
|
| Rate for Payer: Cash Price |
$258.86
|
| Rate for Payer: Devoted Health Medicare |
$175.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$182.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$182.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.52
|
| Rate for Payer: Health Management Network Commercial |
$366.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$191.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$182.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$159.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$182.72
|
|
|
PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$215.90
|
|
|
Service Code
|
HCPCS 99203
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$70.97 |
| Max. Negotiated Rate |
$183.51 |
| Rate for Payer: AlohaCare Medicaid |
$82.26
|
| Rate for Payer: AlohaCare Medicare |
$70.97
|
| Rate for Payer: Cash Price |
$129.54
|
| Rate for Payer: Cash Price |
$129.54
|
| Rate for Payer: Devoted Health Medicare |
$78.07
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$82.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$82.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.24
|
| Rate for Payer: Health Management Network Commercial |
$183.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.26
|
|
|
PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$324.26
|
|
|
Service Code
|
HCPCS 99204
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$112.99 |
| Max. Negotiated Rate |
$275.62 |
| Rate for Payer: AlohaCare Medicaid |
$134.25
|
| Rate for Payer: AlohaCare Medicare |
$116.55
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Cash Price |
$194.56
|
| Rate for Payer: Devoted Health Medicare |
$128.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$134.25
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$134.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.99
|
| Rate for Payer: Health Management Network Commercial |
$275.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$139.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$134.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$116.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$134.25
|
|
|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$139.81
|
|
|
Service Code
|
HCPCS 99202
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$41.15 |
| Max. Negotiated Rate |
$118.84 |
| Rate for Payer: AlohaCare Medicaid |
$47.75
|
| Rate for Payer: AlohaCare Medicare |
$41.15
|
| Rate for Payer: Cash Price |
$83.89
|
| Rate for Payer: Cash Price |
$83.89
|
| Rate for Payer: Devoted Health Medicare |
$45.27
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$47.75
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$47.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.98
|
| Rate for Payer: Health Management Network Commercial |
$118.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.75
|
|
|
PROGEL EXTENDED APPLICATOR TIP
|
Facility
|
OP
|
$626.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$313.00 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: AlohaCare Medicaid |
$313.00
|
| Rate for Payer: AlohaCare Medicare |
$475.76
|
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Devoted Health Medicare |
$525.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$475.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$594.70
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Humana Medicare |
$475.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$319.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$475.76
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$475.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$475.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$475.76
|
| Rate for Payer: University Health Alliance Commercial |
$456.29
|
|
|
PROGEL EXTENDED APPLICATOR TIP
|
Facility
|
IP
|
$626.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$532.10 |
| Max. Negotiated Rate |
$607.22 |
| Rate for Payer: Cash Price |
$375.60
|
| Rate for Payer: Health Management Network Commercial |
$532.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$563.40
|
| Rate for Payer: MDX Hawaii PPO |
$607.22
|
|
|
PROGEL PLEURAL AIR LEAK SEALAN
|
Facility
|
OP
|
$2,424.00
|
|
|
Service Code
|
HCPCS C2615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,212.00 |
| Max. Negotiated Rate |
$2,351.28 |
| Rate for Payer: AlohaCare Medicaid |
$1,212.00
|
| Rate for Payer: AlohaCare Medicare |
$1,842.24
|
| Rate for Payer: Cash Price |
$1,454.40
|
| Rate for Payer: Devoted Health Medicare |
$2,036.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,842.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,696.80
|
| Rate for Payer: Health Management Network Commercial |
$2,060.40
|
| Rate for Payer: Humana Medicare |
$1,842.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,181.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,236.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,842.24
|
| Rate for Payer: MDX Hawaii PPO |
$2,351.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,842.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,842.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,842.24
|
| Rate for Payer: University Health Alliance Commercial |
$1,357.44
|
|
|
PROGEL PLEURAL AIR LEAK SEALAN
|
Facility
|
IP
|
$2,424.00
|
|
|
Service Code
|
HCPCS C2615
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,357.44 |
| Max. Negotiated Rate |
$2,351.28 |
| Rate for Payer: Cash Price |
$1,454.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,696.80
|
| Rate for Payer: Health Management Network Commercial |
$2,060.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,181.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,351.28
|
| Rate for Payer: University Health Alliance Commercial |
$1,357.44
|
|
|
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J2675
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: AlohaCare Medicare |
$95.76
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Devoted Health Medicare |
$105.84
|
| Rate for Payer: Devoted Health Medicare |
$70.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.63
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$95.76
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J2675
|
|
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 |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
PROGRAMMER SMART TH90G01
|
Facility
|
IP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,184.00 |
| Max. Negotiated Rate |
$3,783.00 |
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,730.00
|
| Rate for Payer: Health Management Network Commercial |
$3,315.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,510.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,783.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,184.00
|
|
|
PROGRAMMER SMART TH90G01
|
Facility
|
OP
|
$3,900.00
|
|
|
Service Code
|
HCPCS C1787
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$3,783.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,950.00
|
| Rate for Payer: AlohaCare Medicare |
$2,964.00
|
| Rate for Payer: Cash Price |
$2,340.00
|
| Rate for Payer: Devoted Health Medicare |
$3,276.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,964.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,730.00
|
| Rate for Payer: Health Management Network Commercial |
$3,315.00
|
| Rate for Payer: Humana Medicare |
$2,964.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,510.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,989.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,964.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,783.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,964.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,964.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,964.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,184.00
|
|
