|
PREGABALIN 25 MG PO CAP
|
Facility
|
OP
|
$50.36
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.18 |
| Max. Negotiated Rate |
$49.86 |
| Rate for Payer: AlohaCare Medicaid |
$25.18
|
| Rate for Payer: AlohaCare Medicaid |
$4.46
|
| Rate for Payer: AlohaCare Medicare |
$45.32
|
| Rate for Payer: AlohaCare Medicare |
$8.04
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$32.73
|
| Rate for Payer: Devoted Health Medicare |
$49.86
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$47.84
|
| Rate for Payer: Health Management Network Commercial |
$42.81
|
| Rate for Payer: Health Management Network Commercial |
$7.59
|
| Rate for Payer: Humana Medicare |
$8.04
|
| Rate for Payer: Humana Medicare |
$45.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.32
|
| Rate for Payer: MDX Hawaii PPO |
$8.66
|
| Rate for Payer: MDX Hawaii PPO |
$48.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.04
|
| Rate for Payer: University Health Alliance Commercial |
$6.51
|
| Rate for Payer: University Health Alliance Commercial |
$36.71
|
|
|
PREGABALIN 25 MG PO CAP
|
Facility
|
IP
|
$8.93
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$32.73
|
| Rate for Payer: Health Management Network Commercial |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$42.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.32
|
| Rate for Payer: MDX Hawaii PPO |
$48.85
|
| Rate for Payer: MDX Hawaii PPO |
$8.66
|
|
|
PREGABALIN 50 MG PO CAP
|
Facility
|
OP
|
$4.17
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: AlohaCare Medicaid |
$2.08
|
| Rate for Payer: AlohaCare Medicaid |
$4.46
|
| Rate for Payer: AlohaCare Medicare |
$3.75
|
| Rate for Payer: AlohaCare Medicare |
$8.04
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Devoted Health Medicare |
$4.13
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.96
|
| Rate for Payer: Health Management Network Commercial |
$3.54
|
| Rate for Payer: Health Management Network Commercial |
$7.59
|
| Rate for Payer: Humana Medicare |
$8.04
|
| Rate for Payer: Humana Medicare |
$3.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.75
|
| Rate for Payer: MDX Hawaii PPO |
$8.66
|
| Rate for Payer: MDX Hawaii PPO |
$4.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.04
|
| Rate for Payer: University Health Alliance Commercial |
$6.51
|
| Rate for Payer: University Health Alliance Commercial |
$3.04
|
|
|
PREGABALIN 50 MG PO CAP
|
Facility
|
IP
|
$8.93
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$2.71
|
| Rate for Payer: Health Management Network Commercial |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$3.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.75
|
| Rate for Payer: MDX Hawaii PPO |
$4.04
|
| Rate for Payer: MDX Hawaii PPO |
$8.66
|
|
|
PREGABALIN 75 MG PO CAP
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.12 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: AlohaCare Medicaid |
$2.12
|
| Rate for Payer: AlohaCare Medicaid |
$4.46
|
| Rate for Payer: AlohaCare Medicare |
$3.82
|
| Rate for Payer: AlohaCare Medicare |
$8.04
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.03
|
| Rate for Payer: Health Management Network Commercial |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$7.59
|
| Rate for Payer: Humana Medicare |
$8.04
|
| Rate for Payer: Humana Medicare |
$3.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.82
|
| Rate for Payer: MDX Hawaii PPO |
$8.66
|
| Rate for Payer: MDX Hawaii PPO |
$4.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.04
|
| Rate for Payer: University Health Alliance Commercial |
$6.51
|
| Rate for Payer: University Health Alliance Commercial |
$3.09
|
|
|
PREGABALIN 75 MG PO CAP
|
Facility
|
IP
|
$8.93
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.59 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Health Management Network Commercial |
$7.59
|
| Rate for Payer: Health Management Network Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.82
|
| Rate for Payer: MDX Hawaii PPO |
$4.11
|
| Rate for Payer: MDX Hawaii PPO |
$8.66
|
|
|
PREMATURITY WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$61,577.80
|
|
|
Service Code
|
MSDRG 791
|
| Min. Negotiated Rate |
$61,577.80 |
| Max. Negotiated Rate |
$61,577.80 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$61,577.80
|
|
|
PREMATURITY WITHOUT MAJOR PROBLEMS
|
Facility
|
IP
|
$12,325.04
|
|
|
Service Code
|
MSDRG 792
|
| Min. Negotiated Rate |
$12,325.04 |
| Max. Negotiated Rate |
$12,325.04 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$12,325.04
|
|
|
Prevena Plus Sys Kit Customizable PRE4001US [3642453]
|
Facility
|
IP
|
$3,428.00
|
|
| Hospital Charge Code |
3642453.0
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,913.80 |
| Max. Negotiated Rate |
$3,325.16 |
| Rate for Payer: Cash Price |
$2,228.20
|
| Rate for Payer: Health Management Network Commercial |
$2,913.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,085.20
|
| Rate for Payer: MDX Hawaii PPO |
$3,325.16
|
|
|
Prevena Plus Sys Kit Customizable PRE4001US [3642453]
|
Facility
|
OP
|
$3,428.00
|
|
| Hospital Charge Code |
3642453.0
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,714.00 |
| Max. Negotiated Rate |
$3,393.72 |
| Rate for Payer: AlohaCare Medicaid |
$1,714.00
|
| Rate for Payer: AlohaCare Medicare |
$3,085.20
|
| Rate for Payer: Cash Price |
$2,228.20
|
| Rate for Payer: Devoted Health Medicare |
$3,393.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,085.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,256.60
|
| Rate for Payer: Health Management Network Commercial |
$2,913.80
|
| Rate for Payer: Humana Medicare |
$3,085.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,085.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,748.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,085.20
|
| Rate for Payer: MDX Hawaii PPO |
$3,325.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,085.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,085.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,085.20
|
| Rate for Payer: University Health Alliance Commercial |
$2,498.67
|
|
|
PROCHLORPERAZINE 25 MG PR SUPP
|
Facility
|
OP
|
$68.76
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.38 |
| Max. Negotiated Rate |
$68.07 |
| Rate for Payer: AlohaCare Medicaid |
$34.38
|
| Rate for Payer: AlohaCare Medicare |
$61.88
|
| Rate for Payer: Cash Price |
$44.69
|
| Rate for Payer: Devoted Health Medicare |
$68.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.32
|
| Rate for Payer: Health Management Network Commercial |
$58.45
|
| Rate for Payer: Humana Medicare |
$61.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.88
|
| Rate for Payer: MDX Hawaii PPO |
$66.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.88
|
| Rate for Payer: University Health Alliance Commercial |
$50.12
|
|
|
PROCHLORPERAZINE 25 MG PR SUPP
|
Facility
|
IP
|
$68.76
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.45 |
| Max. Negotiated Rate |
$66.70 |
| Rate for Payer: Cash Price |
$44.69
|
| Rate for Payer: Health Management Network Commercial |
$58.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.88
|
| Rate for Payer: MDX Hawaii PPO |
$66.70
|
|
|
PROCHLORPERAZINE EDISYLATE 5 (5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$30.64
|
|
|
Service Code
|
HCPCS J0780
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$29.72 |
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Health Management Network Commercial |
$52.56
|
| Rate for Payer: Health Management Network Commercial |
$26.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.65
|
| Rate for Payer: MDX Hawaii PPO |
$59.98
|
| Rate for Payer: MDX Hawaii PPO |
$29.72
|
|
|
PROCHLORPERAZINE EDISYLATE 5 (5 MG/ML) INJ SOLN
|
Facility
|
OP
|
$30.64
|
|
|
Service Code
|
HCPCS J0780
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$30.33 |
| Rate for Payer: AlohaCare Medicaid |
$15.32
|
| Rate for Payer: AlohaCare Medicaid |
$30.91
|
| Rate for Payer: AlohaCare Medicare |
$55.65
|
| Rate for Payer: AlohaCare Medicare |
$27.58
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Devoted Health Medicare |
$30.33
|
| Rate for Payer: Devoted Health Medicare |
$61.21
|
| 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 |
$55.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.58
|
| 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 |
$58.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.11
|
| Rate for Payer: Health Management Network Commercial |
$26.04
|
| Rate for Payer: Health Management Network Commercial |
$52.56
|
| Rate for Payer: Humana Medicare |
$55.65
|
| Rate for Payer: Humana Medicare |
$27.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$55.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.58
|
| Rate for Payer: MDX Hawaii PPO |
$29.72
|
| Rate for Payer: MDX Hawaii PPO |
$59.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$37.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.58
|
| Rate for Payer: University Health Alliance Commercial |
$22.33
|
| Rate for Payer: University Health Alliance Commercial |
$45.07
|
|
|
PROCHLORPERAZINE MALEATE 10 MG PO TABLET
|
Facility
|
IP
|
$4.93
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Health Management Network Commercial |
$4.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.44
|
| Rate for Payer: MDX Hawaii PPO |
$4.78
|
|
|
PROCHLORPERAZINE MALEATE 10 MG PO TABLET
|
Facility
|
OP
|
$4.93
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$4.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.46
|
| Rate for Payer: AlohaCare Medicare |
$4.44
|
| Rate for Payer: Cash Price |
$3.20
|
| Rate for Payer: Devoted Health Medicare |
$4.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.68
|
| Rate for Payer: Health Management Network Commercial |
$4.19
|
| Rate for Payer: Humana Medicare |
$4.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.44
|
| Rate for Payer: MDX Hawaii PPO |
$4.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.44
|
| Rate for Payer: University Health Alliance Commercial |
$3.59
|
|
|
PROMETHAZINE 12.5 MG PR SUPP
|
Facility
|
OP
|
$91.30
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.65 |
| Max. Negotiated Rate |
$90.39 |
| Rate for Payer: AlohaCare Medicaid |
$45.65
|
| Rate for Payer: AlohaCare Medicare |
$82.17
|
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Devoted Health Medicare |
$90.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.73
|
| Rate for Payer: Health Management Network Commercial |
$77.61
|
| Rate for Payer: Humana Medicare |
$82.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.17
|
| Rate for Payer: MDX Hawaii PPO |
$88.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.17
|
| Rate for Payer: University Health Alliance Commercial |
$66.55
|
|
|
PROMETHAZINE 12.5 MG PR SUPP
|
Facility
|
IP
|
$91.30
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.61 |
| Max. Negotiated Rate |
$88.56 |
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Health Management Network Commercial |
$77.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.17
|
| Rate for Payer: MDX Hawaii PPO |
$88.56
|
|
|
PROMETHAZINE 25 MG/ML INJ SOLN 1 ML
|
Facility
|
OP
|
$10.21
|
|
|
Service Code
|
HCPCS J2550
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$10.11 |
| Rate for Payer: AlohaCare Medicaid |
$5.11
|
| Rate for Payer: AlohaCare Medicare |
$9.19
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Devoted Health Medicare |
$10.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.19
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.70
|
| Rate for Payer: Health Management Network Commercial |
$8.68
|
| Rate for Payer: Humana Medicare |
$9.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.19
|
| Rate for Payer: MDX Hawaii PPO |
$9.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.13
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.19
|
| Rate for Payer: University Health Alliance Commercial |
$7.44
|
|
|
PROMETHAZINE 25 MG/ML INJ SOLN 1 ML
|
Facility
|
IP
|
$10.21
|
|
|
Service Code
|
HCPCS J2550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Cash Price |
$6.64
|
| Rate for Payer: Health Management Network Commercial |
$8.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.19
|
| Rate for Payer: MDX Hawaii PPO |
$9.90
|
|
|
PROMETHAZINE 25 MG PO TABLET
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.77 |
| Rate for Payer: AlohaCare Medicaid |
$1.40
|
| Rate for Payer: AlohaCare Medicare |
$2.52
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Devoted Health Medicare |
$2.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.66
|
| Rate for Payer: Health Management Network Commercial |
$2.38
|
| Rate for Payer: Humana Medicare |
$2.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.52
|
| Rate for Payer: MDX Hawaii PPO |
$2.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.52
|
| Rate for Payer: University Health Alliance Commercial |
$2.04
|
|
|
PROMETHAZINE 25 MG PO TABLET
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: Health Management Network Commercial |
$2.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: MDX Hawaii PPO |
$2.72
|
|
|
PROMETHAZINE 25 MG PR SUPP
|
Facility
|
OP
|
$91.30
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.65 |
| Max. Negotiated Rate |
$90.39 |
| Rate for Payer: AlohaCare Medicaid |
$45.65
|
| Rate for Payer: AlohaCare Medicare |
$82.17
|
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Devoted Health Medicare |
$90.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$82.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.73
|
| Rate for Payer: Health Management Network Commercial |
$77.61
|
| Rate for Payer: Humana Medicare |
$82.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.17
|
| Rate for Payer: MDX Hawaii PPO |
$88.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$82.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$82.17
|
| Rate for Payer: University Health Alliance Commercial |
$66.55
|
|
|
PROMETHAZINE 25 MG PR SUPP
|
Facility
|
IP
|
$91.30
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.61 |
| Max. Negotiated Rate |
$88.56 |
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Health Management Network Commercial |
$77.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.17
|
| Rate for Payer: MDX Hawaii PPO |
$88.56
|
|
|
PROMETHAZINE-CODEINE 6.25-10 MG/5 ML PO SYRUP
|
Facility
|
IP
|
$1.91
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$1.85 |
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Health Management Network Commercial |
$1.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.72
|
| Rate for Payer: MDX Hawaii PPO |
$1.85
|
|
