|
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
|
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
|
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
|
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
|
|
|
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: Devoted Health Medicare |
$106.79
|
| Rate for Payer: AlohaCare Medicaid |
$97.08
|
| Rate for Payer: AlohaCare Medicare |
$97.08
|
| Rate for Payer: Cash Price |
$126.21
|
| 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
|
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
|
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
|
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
|
|
|
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
|
|
|
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
|
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
|
|
|
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
|
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
|
$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
|
$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
|
$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
|
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
|
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
|
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
|
|
|
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 |
$943.60
|
|
|
PROSTATECTOMY WITH CC
|
Facility
|
IP
|
$22,564.30
|
|
|
Service Code
|
MSDRG 666
|
| Min. Negotiated Rate |
$22,564.30 |
| Max. Negotiated Rate |
$22,564.30 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22,564.30
|
|
