|
PREMATURITY WITHOUT MAJOR PROBLEMS
|
Facility
|
IP
|
$13,257.92
|
|
|
Service Code
|
MSDRG 792
|
| Min. Negotiated Rate |
$13,257.92 |
| Max. Negotiated Rate |
$13,257.92 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$13,257.92
|
|
|
Prenatal III Panel (CBC, RPR, RBGG, HBSAg, ABORH, Ab Screen) FSI
|
Facility
|
OP
|
$207.00
|
|
|
Service Code
|
HCPCS 86762
|
| Hospital Charge Code |
8118018
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: AlohaCare Medicaid |
$103.50
|
| Rate for Payer: AlohaCare Medicare |
$103.50
|
| Rate for Payer: Cash Price |
$134.55
|
| Rate for Payer: Cash Price |
$134.55
|
| Rate for Payer: Devoted Health Medicare |
$113.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$19.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.39
|
| Rate for Payer: Health Management Network Commercial |
$175.95
|
| Rate for Payer: Humana Medicare |
$103.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$186.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.50
|
| Rate for Payer: MDX Hawaii PPO |
$200.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.50
|
| Rate for Payer: University Health Alliance Commercial |
$37.20
|
|
|
Prenatal III Panel (CBC, RPR, RBGG, HBSAg, ABORH, Ab Screen) FSI
|
Facility
|
IP
|
$207.00
|
|
|
Service Code
|
HCPCS 86762
|
| Hospital Charge Code |
8118018
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$175.95 |
| Max. Negotiated Rate |
$200.79 |
| Rate for Payer: Cash Price |
$134.55
|
| Rate for Payer: Health Management Network Commercial |
$175.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$186.30
|
| Rate for Payer: MDX Hawaii PPO |
$200.79
|
|
|
Preterm Labor Trmt Addl Hr Charge
|
Facility
|
OP
|
$389.00
|
|
| Hospital Charge Code |
8140421
|
|
Hospital Revenue Code
|
721
|
| Min. Negotiated Rate |
$194.50 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: AlohaCare Medicaid |
$194.50
|
| Rate for Payer: AlohaCare Medicare |
$194.50
|
| Rate for Payer: Cash Price |
$252.85
|
| Rate for Payer: Devoted Health Medicare |
$213.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$369.55
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Humana Medicare |
$194.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$198.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$194.50
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$194.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.50
|
| Rate for Payer: University Health Alliance Commercial |
$283.54
|
|
|
Preterm Labor Trmt Addl Hr Charge
|
Facility
|
IP
|
$389.00
|
|
| Hospital Charge Code |
8140421
|
|
Hospital Revenue Code
|
721
|
| Min. Negotiated Rate |
$330.65 |
| Max. Negotiated Rate |
$377.33 |
| Rate for Payer: Cash Price |
$252.85
|
| Rate for Payer: Health Management Network Commercial |
$330.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$350.10
|
| Rate for Payer: MDX Hawaii PPO |
$377.33
|
|
|
Preterm Labor Trmt Initial Hr Charge
|
Facility
|
IP
|
$510.00
|
|
| Hospital Charge Code |
8140422
|
|
Hospital Revenue Code
|
721
|
| Min. Negotiated Rate |
$433.50 |
| Max. Negotiated Rate |
$494.70 |
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Health Management Network Commercial |
$433.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$459.00
|
| Rate for Payer: MDX Hawaii PPO |
$494.70
|
|
|
Preterm Labor Trmt Initial Hr Charge
|
Facility
|
OP
|
$510.00
|
|
| Hospital Charge Code |
8140422
|
|
Hospital Revenue Code
|
721
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$494.70 |
| Rate for Payer: AlohaCare Medicaid |
$255.00
|
| Rate for Payer: AlohaCare Medicare |
$255.00
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Devoted Health Medicare |
$280.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$255.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$484.50
|
| Rate for Payer: Health Management Network Commercial |
$433.50
|
| Rate for Payer: Humana Medicare |
$255.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$459.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$260.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$255.00
|
| Rate for Payer: MDX Hawaii PPO |
$494.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$255.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$255.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$255.00
|
| Rate for Payer: University Health Alliance Commercial |
$371.74
|
|
|
PRIMO FIT EXTERNAL URINE MANAGEMENT FOR MALE
|
Facility
|
OP
|
$183.00
|
|
| Hospital Charge Code |
9467532
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$91.50 |
| Max. Negotiated Rate |
$177.51 |
| Rate for Payer: AlohaCare Medicaid |
$91.50
|
| Rate for Payer: AlohaCare Medicare |
$91.50
|
| Rate for Payer: Cash Price |
$118.95
|
| Rate for Payer: Devoted Health Medicare |
$100.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$173.85
|
| Rate for Payer: Health Management Network Commercial |
$155.55
|
| Rate for Payer: Humana Medicare |
$91.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.50
|
| Rate for Payer: MDX Hawaii PPO |
$177.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.50
|
| Rate for Payer: University Health Alliance Commercial |
$133.39
|
|
|
PRIMO FIT EXTERNAL URINE MANAGEMENT FOR MALE
|
Facility
|
IP
|
$183.00
|
|
| Hospital Charge Code |
9467532
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$155.55 |
| Max. Negotiated Rate |
$177.51 |
| Rate for Payer: Cash Price |
$118.95
|
| Rate for Payer: Health Management Network Commercial |
$155.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$164.70
|
| Rate for Payer: MDX Hawaii PPO |
$177.51
|
|
|
procainamide 1000 mg/10 ml vial [HHSC]
|
Facility
|
IP
|
$430.04
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
2500696
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$365.53 |
| Max. Negotiated Rate |
$417.14 |
| Rate for Payer: Cash Price |
$279.53
|
| Rate for Payer: Cash Price |
$343.14
|
| Rate for Payer: Health Management Network Commercial |
$365.53
|
| Rate for Payer: Health Management Network Commercial |
$448.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$475.12
|
| Rate for Payer: MDX Hawaii PPO |
$512.07
|
| Rate for Payer: MDX Hawaii PPO |
$417.14
|
|
|
procainamide 1000 mg/10 ml vial [HHSC]
|
Facility
|
OP
|
$430.04
|
|
|
Service Code
|
HCPCS J2690
|
| Hospital Charge Code |
2500696
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$194.32 |
| Max. Negotiated Rate |
$417.14 |
| Rate for Payer: AlohaCare Medicaid |
$215.02
|
| Rate for Payer: AlohaCare Medicaid |
$263.95
|
| Rate for Payer: AlohaCare Medicare |
$263.95
|
| Rate for Payer: AlohaCare Medicare |
$215.02
|
| Rate for Payer: Cash Price |
$343.14
|
| Rate for Payer: Cash Price |
$279.53
|
| Rate for Payer: Cash Price |
$343.14
|
| Rate for Payer: Cash Price |
$279.53
|
| Rate for Payer: Devoted Health Medicare |
$236.52
|
| Rate for Payer: Devoted Health Medicare |
$290.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$194.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$194.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$268.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$268.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$263.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.02
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$194.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$194.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$408.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$501.51
|
| Rate for Payer: Health Management Network Commercial |
$448.72
|
| Rate for Payer: Health Management Network Commercial |
$365.53
|
| Rate for Payer: Humana Medicare |
$215.02
|
| Rate for Payer: Humana Medicare |
$263.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$387.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$475.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$269.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$219.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$215.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$263.95
|
| Rate for Payer: MDX Hawaii PPO |
$417.14
|
| Rate for Payer: MDX Hawaii PPO |
$512.07
|
| Rate for Payer: Ohana Health Plan Medicaid |
$263.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$215.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$263.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$316.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$258.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$263.95
|
| Rate for Payer: University Health Alliance Commercial |
$313.46
|
| Rate for Payer: University Health Alliance Commercial |
$384.79
|
|
|
Procalcitonin REF
|
Facility
|
OP
|
$319.00
|
|
|
Service Code
|
HCPCS 84145
|
| Hospital Charge Code |
8160204
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.22 |
| Max. Negotiated Rate |
$309.43 |
| Rate for Payer: AlohaCare Medicaid |
$159.50
|
| Rate for Payer: AlohaCare Medicare |
$159.50
|
| Rate for Payer: Cash Price |
$207.35
|
| Rate for Payer: Cash Price |
$207.35
|
| Rate for Payer: Devoted Health Medicare |
$175.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$27.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$34.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$159.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.22
|
| Rate for Payer: Health Management Network Commercial |
$271.15
|
| Rate for Payer: Humana Medicare |
$159.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$287.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$162.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$159.50
|
| Rate for Payer: MDX Hawaii PPO |
$309.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$159.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$159.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$159.50
|
| Rate for Payer: University Health Alliance Commercial |
$51.36
|
|
|
Procalcitonin REF
|
Facility
|
IP
|
$319.00
|
|
|
Service Code
|
HCPCS 84145
|
| Hospital Charge Code |
8160204
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$271.15 |
| Max. Negotiated Rate |
$309.43 |
| Rate for Payer: Cash Price |
$207.35
|
| Rate for Payer: Health Management Network Commercial |
$271.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$287.10
|
| Rate for Payer: MDX Hawaii PPO |
$309.43
|
|
|
prochlorperazine 10 mg/2 ml vial [HHSC]
|
Facility
|
IP
|
$110.95
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
2500699
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.31 |
| Max. Negotiated Rate |
$107.62 |
| Rate for Payer: Cash Price |
$72.12
|
| Rate for Payer: Cash Price |
$26.42
|
| Rate for Payer: Health Management Network Commercial |
$94.31
|
| Rate for Payer: Health Management Network Commercial |
$34.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.59
|
| Rate for Payer: MDX Hawaii PPO |
$39.43
|
| Rate for Payer: MDX Hawaii PPO |
$107.62
|
|
|
prochlorperazine 10 mg/2 ml vial [HHSC]
|
Facility
|
OP
|
$110.95
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
2500699
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$107.62 |
| Rate for Payer: AlohaCare Medicaid |
$55.48
|
| Rate for Payer: AlohaCare Medicaid |
$20.32
|
| Rate for Payer: AlohaCare Medicare |
$20.32
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: Cash Price |
$26.42
|
| Rate for Payer: Cash Price |
$72.12
|
| Rate for Payer: Cash Price |
$72.12
|
| Rate for Payer: Cash Price |
$26.42
|
| Rate for Payer: Devoted Health Medicare |
$61.02
|
| Rate for Payer: Devoted Health Medicare |
$22.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.62
|
| Rate for Payer: Health Management Network Commercial |
$34.55
|
| Rate for Payer: Health Management Network Commercial |
$94.31
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Humana Medicare |
$20.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.32
|
| Rate for Payer: MDX Hawaii PPO |
$107.62
|
| Rate for Payer: MDX Hawaii PPO |
$39.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.32
|
| Rate for Payer: University Health Alliance Commercial |
$80.87
|
| Rate for Payer: University Health Alliance Commercial |
$29.63
|
|
|
prochlorperazine 5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.31
|
|
|
Service Code
|
HCPCS Q0164
|
| Hospital Charge Code |
2500698
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: AlohaCare Medicaid |
$1.66
|
| Rate for Payer: AlohaCare Medicaid |
$1.71
|
| Rate for Payer: AlohaCare Medicaid |
$1.65
|
| Rate for Payer: AlohaCare Medicare |
$1.71
|
| Rate for Payer: AlohaCare Medicare |
$1.66
|
| Rate for Payer: AlohaCare Medicare |
$1.65
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Devoted Health Medicare |
$1.88
|
| Rate for Payer: Devoted Health Medicare |
$1.82
|
| Rate for Payer: Devoted Health Medicare |
$1.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.24
|
| Rate for Payer: Health Management Network Commercial |
$2.81
|
| Rate for Payer: Health Management Network Commercial |
$2.81
|
| Rate for Payer: Health Management Network Commercial |
$2.90
|
| Rate for Payer: Humana Medicare |
$1.65
|
| Rate for Payer: Humana Medicare |
$1.71
|
| Rate for Payer: Humana Medicare |
$1.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.71
|
| Rate for Payer: MDX Hawaii PPO |
$3.20
|
| Rate for Payer: MDX Hawaii PPO |
$3.31
|
| Rate for Payer: MDX Hawaii PPO |
$3.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.65
|
| Rate for Payer: University Health Alliance Commercial |
$2.49
|
| Rate for Payer: University Health Alliance Commercial |
$2.41
|
| Rate for Payer: University Health Alliance Commercial |
$2.41
|
|
|
prochlorperazine 5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.41
|
|
|
Service Code
|
HCPCS Q0164
|
| Hospital Charge Code |
2500698
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Health Management Network Commercial |
$2.90
|
| Rate for Payer: Health Management Network Commercial |
$2.81
|
| Rate for Payer: Health Management Network Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.07
|
| Rate for Payer: MDX Hawaii PPO |
$3.20
|
| Rate for Payer: MDX Hawaii PPO |
$3.21
|
| Rate for Payer: MDX Hawaii PPO |
$3.31
|
|
|
Progesterone FSI
|
Facility
|
OP
|
$239.00
|
|
|
Service Code
|
HCPCS 84144
|
| Hospital Charge Code |
8118020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$231.83 |
| Rate for Payer: AlohaCare Medicaid |
$119.50
|
| Rate for Payer: AlohaCare Medicare |
$119.50
|
| Rate for Payer: Cash Price |
$155.35
|
| Rate for Payer: Cash Price |
$155.35
|
| Rate for Payer: Devoted Health Medicare |
$131.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$28.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$119.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$30.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.86
|
| Rate for Payer: Health Management Network Commercial |
$203.15
|
| Rate for Payer: Humana Medicare |
$119.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$215.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$121.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$119.50
|
| Rate for Payer: MDX Hawaii PPO |
$231.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$119.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$119.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$119.50
|
| Rate for Payer: University Health Alliance Commercial |
$53.93
|
|
|
Progesterone FSI
|
Facility
|
IP
|
$239.00
|
|
|
Service Code
|
HCPCS 84144
|
| Hospital Charge Code |
8118020
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$203.15 |
| Max. Negotiated Rate |
$231.83 |
| Rate for Payer: Cash Price |
$155.35
|
| Rate for Payer: Health Management Network Commercial |
$203.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$215.10
|
| Rate for Payer: MDX Hawaii PPO |
$231.83
|
|
|
Proinsulin FSI
|
Facility
|
OP
|
$204.00
|
|
|
Service Code
|
HCPCS 84206
|
| Hospital Charge Code |
8228912
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.03 |
| Max. Negotiated Rate |
$197.88 |
| Rate for Payer: AlohaCare Medicaid |
$102.00
|
| Rate for Payer: AlohaCare Medicare |
$102.00
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Devoted Health Medicare |
$112.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$33.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$102.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26.69
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Humana Medicare |
$102.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$104.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.00
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.00
|
| Rate for Payer: University Health Alliance Commercial |
$46.05
|
|
|
Proinsulin FSI
|
Facility
|
IP
|
$204.00
|
|
|
Service Code
|
HCPCS 84206
|
| Hospital Charge Code |
8228912
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$173.40 |
| Max. Negotiated Rate |
$197.88 |
| Rate for Payer: Cash Price |
$132.60
|
| Rate for Payer: Health Management Network Commercial |
$173.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$183.60
|
| Rate for Payer: MDX Hawaii PPO |
$197.88
|
|
|
Prolactin FSI
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS 84146
|
| Hospital Charge Code |
8118021
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$234.60 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Health Management Network Commercial |
$234.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$248.40
|
| Rate for Payer: MDX Hawaii PPO |
$267.72
|
|
|
Prolactin FSI
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS 84146
|
| Hospital Charge Code |
8118021
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: AlohaCare Medicaid |
$138.00
|
| Rate for Payer: AlohaCare Medicare |
$138.00
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Cash Price |
$179.40
|
| Rate for Payer: Devoted Health Medicare |
$151.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$26.78
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$138.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$28.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.38
|
| Rate for Payer: Health Management Network Commercial |
$234.60
|
| Rate for Payer: Humana Medicare |
$138.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$248.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$140.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$138.00
|
| Rate for Payer: MDX Hawaii PPO |
$267.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$138.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$138.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$138.00
|
| Rate for Payer: University Health Alliance Commercial |
$50.10
|
|
|
promethazine 25 mg/1 ml vial [HHSC]
|
Facility
|
OP
|
$5.73
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
2500702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$5.56 |
| Rate for Payer: AlohaCare Medicaid |
$2.87
|
| Rate for Payer: AlohaCare Medicaid |
$3.93
|
| Rate for Payer: AlohaCare Medicaid |
$6.95
|
| Rate for Payer: AlohaCare Medicaid |
$6.28
|
| Rate for Payer: AlohaCare Medicare |
$6.28
|
| Rate for Payer: AlohaCare Medicare |
$6.95
|
| Rate for Payer: AlohaCare Medicare |
$2.87
|
| Rate for Payer: AlohaCare Medicare |
$3.93
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Devoted Health Medicare |
$7.64
|
| Rate for Payer: Devoted Health Medicare |
$3.15
|
| Rate for Payer: Devoted Health Medicare |
$6.91
|
| Rate for Payer: Devoted Health Medicare |
$4.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.47
|
| Rate for Payer: Health Management Network Commercial |
$6.68
|
| Rate for Payer: Health Management Network Commercial |
$11.81
|
| Rate for Payer: Health Management Network Commercial |
$10.68
|
| Rate for Payer: Health Management Network Commercial |
$4.87
|
| Rate for Payer: Humana Medicare |
$6.95
|
| Rate for Payer: Humana Medicare |
$6.28
|
| Rate for Payer: Humana Medicare |
$2.87
|
| Rate for Payer: Humana Medicare |
$3.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.28
|
| Rate for Payer: MDX Hawaii PPO |
$7.62
|
| Rate for Payer: MDX Hawaii PPO |
$5.56
|
| Rate for Payer: MDX Hawaii PPO |
$13.48
|
| Rate for Payer: MDX Hawaii PPO |
$12.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.28
|
| Rate for Payer: University Health Alliance Commercial |
$5.73
|
| Rate for Payer: University Health Alliance Commercial |
$4.18
|
| Rate for Payer: University Health Alliance Commercial |
$9.15
|
| Rate for Payer: University Health Alliance Commercial |
$10.13
|
|
|
promethazine 25 mg/1 ml vial [HHSC]
|
Facility
|
IP
|
$13.90
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
2500702
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cash Price |
$8.16
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Health Management Network Commercial |
$10.68
|
| Rate for Payer: Health Management Network Commercial |
$11.81
|
| Rate for Payer: Health Management Network Commercial |
$4.87
|
| Rate for Payer: Health Management Network Commercial |
$6.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.51
|
| Rate for Payer: MDX Hawaii PPO |
$12.18
|
| Rate for Payer: MDX Hawaii PPO |
$5.56
|
| Rate for Payer: MDX Hawaii PPO |
$7.62
|
| Rate for Payer: MDX Hawaii PPO |
$13.48
|
|
