|
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
|
|
|
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
|
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
|
|
|
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
|
|
|
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
|
|
|
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 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
|
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 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
|
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 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 |
$1.69
|
| Rate for Payer: University Health Alliance Commercial |
$1.68
|
|
|
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 6.25-10 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 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 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
|
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
|
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 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
|
|
