|
propofol 1000 mg/100 ml RTU vial [HHSC]
|
Facility
|
IP
|
$126.47
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
2500705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.50 |
| Max. Negotiated Rate |
$122.68 |
| Rate for Payer: Cash Price |
$82.21
|
| Rate for Payer: Cash Price |
$50.92
|
| Rate for Payer: Health Management Network Commercial |
$107.50
|
| Rate for Payer: Health Management Network Commercial |
$66.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.51
|
| Rate for Payer: MDX Hawaii PPO |
$75.99
|
| Rate for Payer: MDX Hawaii PPO |
$122.68
|
|
|
propofol 200 mg/20 ml vial [HHSC]
|
Facility
|
IP
|
$43.65
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
2500706
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$42.34 |
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Health Management Network Commercial |
$37.10
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$42.34
|
|
|
propofol 200 mg/20 ml vial [HHSC]
|
Facility
|
OP
|
$43.65
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
2500706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$42.34 |
| Rate for Payer: AlohaCare Medicaid |
$21.82
|
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$21.82
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Devoted Health Medicare |
$24.01
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| 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 |
$22.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.82
|
| 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 |
$41.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$37.10
|
| Rate for Payer: Humana Medicare |
$21.82
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: MDX Hawaii PPO |
$42.34
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: University Health Alliance Commercial |
$31.82
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 69238207801
|
| Hospital Charge Code |
2500707
|
|
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
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
IP
|
$6.46
|
|
|
Service Code
|
NDC 60687030601
|
| Hospital Charge Code |
2500707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$6.27 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.81
|
| Rate for Payer: MDX Hawaii PPO |
$6.27
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.08
|
|
|
Service Code
|
NDC 60687059801
|
| Hospital Charge Code |
2500707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Health Management Network Commercial |
$2.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.77
|
| Rate for Payer: MDX Hawaii PPO |
$2.99
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
OP
|
$6.46
|
|
|
Service Code
|
NDC 60687030601
|
| Hospital Charge Code |
2500707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$6.27 |
| Rate for Payer: AlohaCare Medicaid |
$3.23
|
| Rate for Payer: AlohaCare Medicare |
$3.23
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$3.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.14
|
| Rate for Payer: Health Management Network Commercial |
$5.49
|
| Rate for Payer: Humana Medicare |
$3.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.29
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.23
|
| Rate for Payer: MDX Hawaii PPO |
$6.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.23
|
| Rate for Payer: University Health Alliance Commercial |
$4.71
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00591555501
|
| Hospital Charge Code |
2500707
|
|
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
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00603548321
|
| Hospital Charge Code |
2500707
|
|
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
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00591555501
|
| Hospital Charge Code |
2500707
|
|
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
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00603548321
|
| Hospital Charge Code |
2500707
|
|
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
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.08
|
|
|
Service Code
|
NDC 60687059801
|
| Hospital Charge Code |
2500707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$2.99 |
| Rate for Payer: AlohaCare Medicaid |
$1.54
|
| Rate for Payer: AlohaCare Medicare |
$1.54
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Devoted Health Medicare |
$1.69
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.93
|
| Rate for Payer: Health Management Network Commercial |
$2.62
|
| Rate for Payer: Humana Medicare |
$1.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.54
|
| Rate for Payer: MDX Hawaii PPO |
$2.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.54
|
| Rate for Payer: University Health Alliance Commercial |
$2.25
|
|
|
propranolol 20 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 69238207801
|
| Hospital Charge Code |
2500707
|
|
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
|
|
|
propylthiouracil 50 mg tablet [HHSC]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 00228234810
|
| Hospital Charge Code |
2500708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
propylthiouracil 50 mg tablet [HHSC]
|
Facility
|
IP
|
$9.68
|
|
|
Service Code
|
NDC 68084096425
|
| Hospital Charge Code |
2500708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.23 |
| Max. Negotiated Rate |
$9.39 |
| Rate for Payer: Cash Price |
$6.29
|
| Rate for Payer: Health Management Network Commercial |
$8.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.71
|
| Rate for Payer: MDX Hawaii PPO |
$9.39
|
|
|
propylthiouracil 50 mg tablet [HHSC]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 67253065110
|
| Hospital Charge Code |
2500708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
propylthiouracil 50 mg tablet [HHSC]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 67253065110
|
| Hospital Charge Code |
2500708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$2.50
|
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Devoted Health Medicare |
$2.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$2.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.50
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
propylthiouracil 50 mg tablet [HHSC]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
NDC 00228234810
|
| Hospital Charge Code |
2500708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicare |
$2.50
|
| Rate for Payer: Cash Price |
$3.25
|
| Rate for Payer: Devoted Health Medicare |
$2.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$2.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.50
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.50
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
|
|
propylthiouracil 50 mg tablet [HHSC]
|
Facility
|
OP
|
$9.68
|
|
|
Service Code
|
NDC 68084096425
|
| Hospital Charge Code |
2500708
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$9.39 |
| Rate for Payer: AlohaCare Medicaid |
$4.84
|
| Rate for Payer: AlohaCare Medicare |
$4.84
|
| Rate for Payer: Cash Price |
$6.29
|
| Rate for Payer: Devoted Health Medicare |
$5.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.20
|
| Rate for Payer: Health Management Network Commercial |
$8.23
|
| Rate for Payer: Humana Medicare |
$4.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.84
|
| Rate for Payer: MDX Hawaii PPO |
$9.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.84
|
| Rate for Payer: University Health Alliance Commercial |
$7.06
|
|
|
Prostate Cancer Biomarker by TMA FSI
|
Facility
|
IP
|
$1,685.00
|
|
|
Service Code
|
HCPCS 81313
|
| Hospital Charge Code |
8727804
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$1,432.25 |
| Max. Negotiated Rate |
$1,634.45 |
| Rate for Payer: Cash Price |
$1,095.25
|
| Rate for Payer: Health Management Network Commercial |
$1,432.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,516.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,634.45
|
|
|
Prostate Cancer Biomarker by TMA FSI
|
Facility
|
OP
|
$1,685.00
|
|
|
Service Code
|
HCPCS 81313
|
| Hospital Charge Code |
8727804
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$191.29 |
| Max. Negotiated Rate |
$1,634.45 |
| Rate for Payer: AlohaCare Medicaid |
$842.50
|
| Rate for Payer: AlohaCare Medicare |
$842.50
|
| Rate for Payer: Cash Price |
$1,095.25
|
| Rate for Payer: Cash Price |
$1,095.25
|
| Rate for Payer: Devoted Health Medicare |
$926.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$260.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$318.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$842.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$260.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$255.05
|
| Rate for Payer: Health Management Network Commercial |
$1,432.25
|
| Rate for Payer: Humana Medicare |
$842.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,516.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$859.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$842.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,634.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$842.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$842.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$191.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$842.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,228.20
|
|
|
PROSTATECTOMY WITH CC
|
Facility
|
IP
|
$24,272.19
|
|
|
Service Code
|
MSDRG 666
|
| Min. Negotiated Rate |
$24,272.19 |
| Max. Negotiated Rate |
$24,272.19 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,272.19
|
|
|
PROSTATECTOMY WITH MCC
|
Facility
|
IP
|
$24,272.19
|
|
|
Service Code
|
MSDRG 665
|
| Min. Negotiated Rate |
$24,272.19 |
| Max. Negotiated Rate |
$24,272.19 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,272.19
|
|
|
PROSTATECTOMY WITHOUT CC/MCC
|
Facility
|
IP
|
$17,133.31
|
|
|
Service Code
|
MSDRG 667
|
| Min. Negotiated Rate |
$17,133.31 |
| Max. Negotiated Rate |
$17,133.31 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$17,133.31
|
|
|
Prosthetic Training Charges
|
Facility
|
OP
|
$260.00
|
|
|
Service Code
|
HCPCS 97761 GP,CQ
|
| Hospital Charge Code |
8111695
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$17.70 |
| Max. Negotiated Rate |
$252.20 |
| Rate for Payer: AlohaCare Medicaid |
$130.00
|
| Rate for Payer: AlohaCare Medicare |
$130.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Cash Price |
$169.00
|
| Rate for Payer: Devoted Health Medicare |
$143.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$130.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$247.00
|
| Rate for Payer: Health Management Network Commercial |
$221.00
|
| Rate for Payer: Humana Medicare |
$130.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$234.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$132.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$130.00
|
| Rate for Payer: MDX Hawaii PPO |
$252.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$130.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$130.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$130.00
|
| Rate for Payer: University Health Alliance Commercial |
$189.51
|
|
