|
promethazine 25 mg suppository [HHSC]
|
Facility
|
OP
|
$92.16
|
|
|
Service Code
|
NDC 45802075930
|
| Hospital Charge Code |
2500700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.08 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: AlohaCare Medicaid |
$46.08
|
| Rate for Payer: AlohaCare Medicare |
$46.08
|
| Rate for Payer: Cash Price |
$59.90
|
| Rate for Payer: Devoted Health Medicare |
$50.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.55
|
| Rate for Payer: Health Management Network Commercial |
$78.34
|
| Rate for Payer: Humana Medicare |
$46.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.08
|
| Rate for Payer: MDX Hawaii PPO |
$89.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.08
|
| Rate for Payer: University Health Alliance Commercial |
$67.18
|
|
|
promethazine 25 mg suppository [HHSC]
|
Facility
|
OP
|
$92.16
|
|
|
Service Code
|
NDC 51672529701
|
| Hospital Charge Code |
2500700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.08 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: AlohaCare Medicaid |
$46.08
|
| Rate for Payer: AlohaCare Medicare |
$46.08
|
| Rate for Payer: Cash Price |
$59.90
|
| Rate for Payer: Devoted Health Medicare |
$50.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.55
|
| Rate for Payer: Health Management Network Commercial |
$78.34
|
| Rate for Payer: Humana Medicare |
$46.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.08
|
| Rate for Payer: MDX Hawaii PPO |
$89.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.08
|
| Rate for Payer: University Health Alliance Commercial |
$67.18
|
|
|
promethazine 25 mg suppository [HHSC]
|
Facility
|
IP
|
$92.16
|
|
|
Service Code
|
NDC 45802075930
|
| Hospital Charge Code |
2500700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.34 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: Cash Price |
$59.90
|
| Rate for Payer: Health Management Network Commercial |
$78.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.94
|
| Rate for Payer: MDX Hawaii PPO |
$89.40
|
|
|
promethazine 25 mg suppository [HHSC]
|
Facility
|
IP
|
$92.16
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
2500700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.34 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: Cash Price |
$59.90
|
| Rate for Payer: Health Management Network Commercial |
$78.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.94
|
| Rate for Payer: MDX Hawaii PPO |
$89.40
|
|
|
promethazine 25 mg suppository [HHSC]
|
Facility
|
IP
|
$92.16
|
|
|
Service Code
|
NDC 51672529701
|
| Hospital Charge Code |
2500700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.34 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: Cash Price |
$59.90
|
| Rate for Payer: Health Management Network Commercial |
$78.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.94
|
| Rate for Payer: MDX Hawaii PPO |
$89.40
|
|
|
promethazine 25 mg suppository [HHSC]
|
Facility
|
OP
|
$92.16
|
|
|
Service Code
|
NDC 00713052612
|
| Hospital Charge Code |
2500700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.08 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: AlohaCare Medicaid |
$46.08
|
| Rate for Payer: AlohaCare Medicare |
$46.08
|
| Rate for Payer: Cash Price |
$59.90
|
| Rate for Payer: Devoted Health Medicare |
$50.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.55
|
| Rate for Payer: Health Management Network Commercial |
$78.34
|
| Rate for Payer: Humana Medicare |
$46.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.08
|
| Rate for Payer: MDX Hawaii PPO |
$89.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$55.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.08
|
| Rate for Payer: University Health Alliance Commercial |
$67.18
|
|
|
promethazine 25 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
2500701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$2.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.71
|
| Rate for Payer: MDX Hawaii PPO |
$2.92
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
promethazine 25 mg tablet [HHSC]
|
Facility
|
OP
|
$3.01
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
2500701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Devoted Health Medicare |
$1.66
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.86
|
| Rate for Payer: Health Management Network Commercial |
$2.56
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$2.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
prometh-cod 6.25-10 mg/5 mL 60 mL [HHSC]
|
Facility
|
IP
|
$46.71
|
|
|
Service Code
|
NDC 00121092816
|
| Hospital Charge Code |
2501120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.70 |
| Max. Negotiated Rate |
$45.31 |
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Health Management Network Commercial |
$39.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.04
|
| Rate for Payer: MDX Hawaii PPO |
$45.31
|
|
|
prometh-cod 6.25-10 mg/5 mL 60 mL [HHSC]
|
Facility
|
OP
|
$46.71
|
|
|
Service Code
|
NDC 00121092816
|
| Hospital Charge Code |
2501120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.36 |
| Max. Negotiated Rate |
$45.31 |
| Rate for Payer: AlohaCare Medicaid |
$23.36
|
| Rate for Payer: AlohaCare Medicare |
$23.36
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Devoted Health Medicare |
$25.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.37
|
| Rate for Payer: Health Management Network Commercial |
$39.70
|
| Rate for Payer: Humana Medicare |
$23.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.36
|
| Rate for Payer: MDX Hawaii PPO |
$45.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.36
|
| Rate for Payer: University Health Alliance Commercial |
$34.05
|
|
|
prometh-cod 6.25 mg-10 mg/5 mL 5 mL U/D [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 27808006502
|
| Hospital Charge Code |
2500907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
prometh-cod 6.25 mg-10 mg/5 mL 5 mL U/D [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50383080416
|
| Hospital Charge Code |
2500907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
prometh-cod 6.25 mg-10 mg/5 mL 5 mL U/D [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60432060616
|
| Hospital Charge Code |
2500907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
prometh-cod 6.25 mg-10 mg/5 mL 5 mL U/D [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50383080416
|
| Hospital Charge Code |
2500907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
prometh-cod 6.25 mg-10 mg/5 mL 5 mL U/D [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60432060616
|
| Hospital Charge Code |
2500907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
prometh-cod 6.25 mg-10 mg/5 mL 5 mL U/D [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 27808006502
|
| Hospital Charge Code |
2500907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
IP
|
$201.07
|
|
|
Service Code
|
NDC 70069060101
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$170.91 |
| Max. Negotiated Rate |
$195.04 |
| Rate for Payer: Cash Price |
$130.70
|
| Rate for Payer: Health Management Network Commercial |
$170.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.96
|
| Rate for Payer: MDX Hawaii PPO |
$195.04
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
IP
|
$194.17
|
|
|
Service Code
|
NDC 24208073006
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$165.04 |
| Max. Negotiated Rate |
$188.34 |
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Health Management Network Commercial |
$165.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.75
|
| Rate for Payer: MDX Hawaii PPO |
$188.34
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
OP
|
$194.17
|
|
|
Service Code
|
NDC 24208073006
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.08 |
| Max. Negotiated Rate |
$188.34 |
| Rate for Payer: AlohaCare Medicaid |
$97.08
|
| Rate for Payer: AlohaCare Medicare |
$97.08
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Devoted Health Medicare |
$106.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$97.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$184.46
|
| Rate for Payer: Health Management Network Commercial |
$165.04
|
| Rate for Payer: Humana Medicare |
$97.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$97.08
|
| Rate for Payer: MDX Hawaii PPO |
$188.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$97.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$97.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$116.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$97.08
|
| Rate for Payer: University Health Alliance Commercial |
$141.53
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
OP
|
$201.53
|
|
|
Service Code
|
NDC 17478026312
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.77 |
| Max. Negotiated Rate |
$195.48 |
| Rate for Payer: AlohaCare Medicaid |
$100.77
|
| Rate for Payer: AlohaCare Medicare |
$100.77
|
| Rate for Payer: Cash Price |
$130.99
|
| Rate for Payer: Devoted Health Medicare |
$110.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.45
|
| Rate for Payer: Health Management Network Commercial |
$171.30
|
| Rate for Payer: Humana Medicare |
$100.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.77
|
| Rate for Payer: MDX Hawaii PPO |
$195.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$120.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.77
|
| Rate for Payer: University Health Alliance Commercial |
$146.90
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
OP
|
$201.07
|
|
|
Service Code
|
NDC 70069060101
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.53 |
| Max. Negotiated Rate |
$195.04 |
| Rate for Payer: AlohaCare Medicaid |
$100.53
|
| Rate for Payer: AlohaCare Medicare |
$100.53
|
| Rate for Payer: Cash Price |
$130.70
|
| Rate for Payer: Devoted Health Medicare |
$110.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.02
|
| Rate for Payer: Health Management Network Commercial |
$170.91
|
| Rate for Payer: Humana Medicare |
$100.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.53
|
| Rate for Payer: MDX Hawaii PPO |
$195.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$120.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.53
|
| Rate for Payer: University Health Alliance Commercial |
$146.56
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
IP
|
$201.53
|
|
|
Service Code
|
NDC 17478026312
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.30 |
| Max. Negotiated Rate |
$195.48 |
| Rate for Payer: Cash Price |
$130.99
|
| Rate for Payer: Health Management Network Commercial |
$171.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.38
|
| Rate for Payer: MDX Hawaii PPO |
$195.48
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
OP
|
$201.57
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.78 |
| Max. Negotiated Rate |
$195.52 |
| Rate for Payer: AlohaCare Medicaid |
$100.78
|
| Rate for Payer: AlohaCare Medicare |
$100.78
|
| Rate for Payer: Cash Price |
$131.02
|
| Rate for Payer: Devoted Health Medicare |
$110.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$191.49
|
| Rate for Payer: Health Management Network Commercial |
$171.33
|
| Rate for Payer: Humana Medicare |
$100.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.78
|
| Rate for Payer: MDX Hawaii PPO |
$195.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$120.94
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.78
|
| Rate for Payer: University Health Alliance Commercial |
$146.92
|
|
|
proparacaine 0.5% ophth drop [HHSC]
|
Facility
|
IP
|
$201.57
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
2500704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$171.33 |
| Max. Negotiated Rate |
$195.52 |
| Rate for Payer: Cash Price |
$131.02
|
| Rate for Payer: Health Management Network Commercial |
$171.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.41
|
| Rate for Payer: MDX Hawaii PPO |
$195.52
|
|
|
propofol 1000 mg/100 ml RTU vial [HHSC]
|
Facility
|
OP
|
$126.47
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
2500705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$122.68 |
| Rate for Payer: AlohaCare Medicaid |
$63.23
|
| Rate for Payer: AlohaCare Medicaid |
$39.17
|
| Rate for Payer: AlohaCare Medicare |
$39.17
|
| Rate for Payer: AlohaCare Medicare |
$63.23
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Cash Price |
$82.21
|
| Rate for Payer: Cash Price |
$82.21
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Devoted Health Medicare |
$69.56
|
| Rate for Payer: Devoted Health Medicare |
$43.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$120.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.42
|
| Rate for Payer: Health Management Network Commercial |
$66.59
|
| Rate for Payer: Health Management Network Commercial |
$107.50
|
| Rate for Payer: Humana Medicare |
$63.23
|
| Rate for Payer: Humana Medicare |
$39.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.17
|
| Rate for Payer: MDX Hawaii PPO |
$122.68
|
| Rate for Payer: MDX Hawaii PPO |
$75.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.17
|
| Rate for Payer: University Health Alliance Commercial |
$92.18
|
| Rate for Payer: University Health Alliance Commercial |
$57.10
|
|
