|
PP silver sulfaDIAZINE 1% 25gm [HHSC]
|
Facility
|
OP
|
$53.85
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530964
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$26.93 |
| Max. Negotiated Rate |
$52.23 |
| Rate for Payer: AlohaCare Medicaid |
$26.93
|
| Rate for Payer: AlohaCare Medicare |
$26.93
|
| Rate for Payer: Cash Price |
$35.00
|
| Rate for Payer: Devoted Health Medicare |
$29.62
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.16
|
| Rate for Payer: Health Management Network Commercial |
$45.77
|
| Rate for Payer: Humana Medicare |
$26.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.93
|
| Rate for Payer: MDX Hawaii PPO |
$52.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.93
|
| Rate for Payer: University Health Alliance Commercial |
$39.25
|
|
|
PP silver sulfaDIAZINE 1% 85gm [HHSC]
|
Facility
|
IP
|
$137.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530963
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.06 |
| Max. Negotiated Rate |
$133.59 |
| Rate for Payer: Cash Price |
$89.52
|
| Rate for Payer: Health Management Network Commercial |
$117.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.95
|
| Rate for Payer: MDX Hawaii PPO |
$133.59
|
|
|
PP silver sulfaDIAZINE 1% 85gm [HHSC]
|
Facility
|
OP
|
$137.72
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530963
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$68.86 |
| Max. Negotiated Rate |
$133.59 |
| Rate for Payer: Kaiser Permanente Medicare |
$68.86
|
| Rate for Payer: AlohaCare Medicaid |
$68.86
|
| Rate for Payer: AlohaCare Medicare |
$68.86
|
| Rate for Payer: Cash Price |
$89.52
|
| Rate for Payer: Devoted Health Medicare |
$75.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$130.83
|
| Rate for Payer: Health Management Network Commercial |
$117.06
|
| Rate for Payer: Humana Medicare |
$68.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.24
|
| Rate for Payer: MDX Hawaii PPO |
$133.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.86
|
| Rate for Payer: University Health Alliance Commercial |
$100.38
|
|
|
PP sulfameth/TMP 800/160 mg #2 [HHSC]
|
Facility
|
OP
|
$3.51
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530966
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: AlohaCare Medicaid |
$1.75
|
| Rate for Payer: AlohaCare Medicaid |
$6.42
|
| Rate for Payer: AlohaCare Medicaid |
$1.64
|
| Rate for Payer: AlohaCare Medicare |
$6.42
|
| Rate for Payer: AlohaCare Medicare |
$1.75
|
| Rate for Payer: AlohaCare Medicare |
$1.64
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Devoted Health Medicare |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$7.06
|
| Rate for Payer: Devoted Health Medicare |
$1.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.19
|
| Rate for Payer: Health Management Network Commercial |
$10.91
|
| Rate for Payer: Health Management Network Commercial |
$2.98
|
| Rate for Payer: Health Management Network Commercial |
$2.78
|
| Rate for Payer: Humana Medicare |
$6.42
|
| Rate for Payer: Humana Medicare |
$1.64
|
| Rate for Payer: Humana Medicare |
$1.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.64
|
| Rate for Payer: MDX Hawaii PPO |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.17
|
| Rate for Payer: MDX Hawaii PPO |
$12.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.42
|
| Rate for Payer: University Health Alliance Commercial |
$2.56
|
| Rate for Payer: University Health Alliance Commercial |
$9.35
|
| Rate for Payer: University Health Alliance Commercial |
$2.38
|
|
|
PP sulfameth/TMP 800/160 mg #2 [HHSC]
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530966
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.98 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Health Management Network Commercial |
$2.98
|
| Rate for Payer: Health Management Network Commercial |
$10.91
|
| Rate for Payer: Health Management Network Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.16
|
| Rate for Payer: MDX Hawaii PPO |
$3.17
|
| Rate for Payer: MDX Hawaii PPO |
$12.45
|
| Rate for Payer: MDX Hawaii PPO |
$3.40
|
|
|
PP sulfa-trim 200-40mg/5mL 120mL [HHSC]
|
Facility
|
IP
|
$290.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530965
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$247.01 |
| Max. Negotiated Rate |
$281.88 |
| Rate for Payer: Cash Price |
$188.89
|
| Rate for Payer: Cash Price |
$89.65
|
| Rate for Payer: Health Management Network Commercial |
$247.01
|
| Rate for Payer: Health Management Network Commercial |
$117.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.13
|
| Rate for Payer: MDX Hawaii PPO |
$133.78
|
| Rate for Payer: MDX Hawaii PPO |
$281.88
|
|
|
PP sulfa-trim 200-40mg/5mL 120mL [HHSC]
|
Facility
|
OP
|
$137.92
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2530965
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$68.96 |
| Max. Negotiated Rate |
$133.78 |
| Rate for Payer: AlohaCare Medicaid |
$68.96
|
| Rate for Payer: AlohaCare Medicaid |
$145.30
|
| Rate for Payer: AlohaCare Medicare |
$68.96
|
| Rate for Payer: AlohaCare Medicare |
$145.30
|
| Rate for Payer: Cash Price |
$188.89
|
| Rate for Payer: Cash Price |
$89.65
|
| Rate for Payer: Devoted Health Medicare |
$75.86
|
| Rate for Payer: Devoted Health Medicare |
$159.83
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$145.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$276.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$131.02
|
| Rate for Payer: Health Management Network Commercial |
$117.23
|
| Rate for Payer: Health Management Network Commercial |
$247.01
|
| Rate for Payer: Humana Medicare |
$145.30
|
| Rate for Payer: Humana Medicare |
$68.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$261.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$148.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$145.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.96
|
| Rate for Payer: MDX Hawaii PPO |
$281.88
|
| Rate for Payer: MDX Hawaii PPO |
$133.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$145.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$145.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$145.30
|
| Rate for Payer: University Health Alliance Commercial |
$211.82
|
| Rate for Payer: University Health Alliance Commercial |
$100.53
|
|
|
PP triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
IP
|
$32.30
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530967
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.45 |
| Max. Negotiated Rate |
$31.33 |
| Rate for Payer: Cash Price |
$20.99
|
| Rate for Payer: Health Management Network Commercial |
$27.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.07
|
| Rate for Payer: MDX Hawaii PPO |
$31.33
|
|
|
PP triamcinolone 0.1% cream 15gm [HHSC]
|
Facility
|
OP
|
$32.30
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
2530967
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$31.33 |
| Rate for Payer: AlohaCare Medicaid |
$16.15
|
| Rate for Payer: AlohaCare Medicare |
$16.15
|
| Rate for Payer: Cash Price |
$20.99
|
| Rate for Payer: Devoted Health Medicare |
$17.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.68
|
| Rate for Payer: Health Management Network Commercial |
$27.45
|
| Rate for Payer: Humana Medicare |
$16.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.15
|
| Rate for Payer: MDX Hawaii PPO |
$31.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.15
|
| Rate for Payer: University Health Alliance Commercial |
$23.54
|
|
|
pravastatin 20 mg tablet [HHSC]
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: AlohaCare Medicaid |
$2.30
|
| Rate for Payer: AlohaCare Medicaid |
$9.04
|
| Rate for Payer: AlohaCare Medicare |
$9.04
|
| Rate for Payer: AlohaCare Medicare |
$2.30
|
| Rate for Payer: Cash Price |
$11.75
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Devoted Health Medicare |
$9.94
|
| Rate for Payer: Devoted Health Medicare |
$2.53
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.37
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.18
|
| Rate for Payer: Health Management Network Commercial |
$15.37
|
| Rate for Payer: Health Management Network Commercial |
$3.91
|
| Rate for Payer: Humana Medicare |
$9.04
|
| Rate for Payer: Humana Medicare |
$2.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.14
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.04
|
| Rate for Payer: MDX Hawaii PPO |
$4.46
|
| Rate for Payer: MDX Hawaii PPO |
$17.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.30
|
| Rate for Payer: University Health Alliance Commercial |
$13.18
|
| Rate for Payer: University Health Alliance Commercial |
$3.35
|
|
|
pravastatin 20 mg tablet [HHSC]
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.91 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cash Price |
$11.75
|
| Rate for Payer: Health Management Network Commercial |
$15.37
|
| Rate for Payer: Health Management Network Commercial |
$3.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.14
|
| Rate for Payer: MDX Hawaii PPO |
$4.46
|
| Rate for Payer: MDX Hawaii PPO |
$17.54
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
IP
|
$10.07
|
|
|
Service Code
|
NDC 51079063020
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Health Management Network Commercial |
$8.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.06
|
| Rate for Payer: MDX Hawaii PPO |
$9.77
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 70756042911
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Health Management Network Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.77
|
| Rate for Payer: MDX Hawaii PPO |
$5.14
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
OP
|
$4.98
|
|
|
Service Code
|
NDC 59651027101
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: AlohaCare Medicaid |
$2.49
|
| Rate for Payer: AlohaCare Medicare |
$2.49
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Devoted Health Medicare |
$2.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.73
|
| Rate for Payer: Health Management Network Commercial |
$4.23
|
| Rate for Payer: Humana Medicare |
$2.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.49
|
| Rate for Payer: MDX Hawaii PPO |
$4.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.49
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.49
|
| Rate for Payer: University Health Alliance Commercial |
$3.63
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
OP
|
$3.36
|
|
|
Service Code
|
NDC 70954001910
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: AlohaCare Medicaid |
$1.68
|
| Rate for Payer: AlohaCare Medicare |
$1.68
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Devoted Health Medicare |
$1.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.19
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Humana Medicare |
$1.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.68
|
| Rate for Payer: MDX Hawaii PPO |
$3.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.68
|
| Rate for Payer: University Health Alliance Commercial |
$2.45
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
IP
|
$5.30
|
|
|
Service Code
|
NDC 00093406701
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Health Management Network Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.77
|
| Rate for Payer: MDX Hawaii PPO |
$5.14
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 00093406701
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: AlohaCare Medicaid |
$2.65
|
| Rate for Payer: AlohaCare Medicare |
$2.65
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Devoted Health Medicare |
$2.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.04
|
| Rate for Payer: Health Management Network Commercial |
$4.50
|
| Rate for Payer: Humana Medicare |
$2.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.65
|
| Rate for Payer: MDX Hawaii PPO |
$5.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.65
|
| Rate for Payer: University Health Alliance Commercial |
$3.86
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
IP
|
$3.36
|
|
|
Service Code
|
NDC 70954001910
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.26
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
OP
|
$9.92
|
|
|
Service Code
|
NDC 68084099601
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$9.62 |
| Rate for Payer: AlohaCare Medicaid |
$4.96
|
| Rate for Payer: AlohaCare Medicare |
$4.96
|
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Devoted Health Medicare |
$5.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.42
|
| Rate for Payer: Health Management Network Commercial |
$8.43
|
| Rate for Payer: Humana Medicare |
$4.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.96
|
| Rate for Payer: MDX Hawaii PPO |
$9.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.96
|
| Rate for Payer: University Health Alliance Commercial |
$7.23
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
OP
|
$5.30
|
|
|
Service Code
|
NDC 70756042911
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$5.14 |
| Rate for Payer: AlohaCare Medicaid |
$2.65
|
| Rate for Payer: AlohaCare Medicare |
$2.65
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Devoted Health Medicare |
$2.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.04
|
| Rate for Payer: Health Management Network Commercial |
$4.50
|
| Rate for Payer: Humana Medicare |
$2.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.65
|
| Rate for Payer: MDX Hawaii PPO |
$5.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.65
|
| Rate for Payer: University Health Alliance Commercial |
$3.86
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
IP
|
$9.92
|
|
|
Service Code
|
NDC 68084099601
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.43 |
| Max. Negotiated Rate |
$9.62 |
| Rate for Payer: Cash Price |
$6.45
|
| Rate for Payer: Health Management Network Commercial |
$8.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.93
|
| Rate for Payer: MDX Hawaii PPO |
$9.62
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
IP
|
$4.98
|
|
|
Service Code
|
NDC 59651027101
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.23 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Health Management Network Commercial |
$4.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.48
|
| Rate for Payer: MDX Hawaii PPO |
$4.83
|
|
|
prazosin 1 mg capsule [HHSC]
|
Facility
|
OP
|
$10.07
|
|
|
Service Code
|
NDC 51079063020
|
| Hospital Charge Code |
2500688
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.04 |
| Max. Negotiated Rate |
$9.77 |
| Rate for Payer: AlohaCare Medicaid |
$5.04
|
| Rate for Payer: AlohaCare Medicare |
$5.04
|
| Rate for Payer: Cash Price |
$6.55
|
| Rate for Payer: Devoted Health Medicare |
$5.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.57
|
| Rate for Payer: Health Management Network Commercial |
$8.56
|
| Rate for Payer: Humana Medicare |
$5.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.04
|
| Rate for Payer: MDX Hawaii PPO |
$9.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.04
|
| Rate for Payer: University Health Alliance Commercial |
$7.34
|
|
|
Pre Albumin FSI
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
HCPCS 84134
|
| Hospital Charge Code |
8118017
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.59 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: AlohaCare Medicaid |
$83.00
|
| Rate for Payer: AlohaCare Medicare |
$83.00
|
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Devoted Health Medicare |
$91.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$20.16
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$18.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$21.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.59
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Humana Medicare |
$83.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.00
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.00
|
| Rate for Payer: University Health Alliance Commercial |
$37.70
|
|
|
Pre Albumin FSI
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
HCPCS 84134
|
| Hospital Charge Code |
8118017
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$141.10 |
| Max. Negotiated Rate |
$161.02 |
| Rate for Payer: Cash Price |
$107.90
|
| Rate for Payer: Health Management Network Commercial |
$141.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.40
|
| Rate for Payer: MDX Hawaii PPO |
$161.02
|
|
