|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 51862045504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 75907002511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 00591351004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH [162636]
|
Facility
|
IP
|
$155.00
|
|
|
Service Code
|
NDC 75907002548
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.75 |
| Max. Negotiated Rate |
$150.35 |
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Health Management Network Commercial |
$131.75
|
| Rate for Payer: MDX Hawaii PPO |
$150.35
|
|
|
CLONIDINE HCL 0.1 MG TABLET [1755]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687011301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CLONIDINE HCL 0.1 MG TABLET [1755]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68001023700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
CLONIDINE HCL 0.1 MG TABLET [1755]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687011301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CLONIDINE HCL 0.1 MG TABLET [1755]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687011311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CLONIDINE HCL 0.1 MG TABLET [1755]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687011311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CLONIDINE HCL 0.1 MG TABLET [1755]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68001023700
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
NDC 68084075225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.17 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.65
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.17
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
| Rate for Payer: University Health Alliance Commercial |
$48.84
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
NDC 68084075218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
NDC 68084075219
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 68084075225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
NDC 68084075218
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
CLOPIDOGREL 300 MG TABLET [89346]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
NDC 68084075219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.79 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 68084053601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 68084053611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 68084053611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
CLOPIDOGREL 75 MG TABLET [22142]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 68084053601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 24505
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$319.62 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$319.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
|
|
CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION
|
Facility
|
OP
|
$5,509.00
|
|
|
Service Code
|
CPT 21320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$5,509.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,916.70
|
| Rate for Payer: AlohaCare Medicare |
$3,916.70
|
| Rate for Payer: Devoted Health Medicare |
$4,308.37
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$695.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5,509.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,916.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,028.67
|
| Rate for Payer: Humana Medicare |
$3,916.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,916.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,308.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,916.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,916.70
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 24655
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$250.88 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$250.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
|
|
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 25505
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,374.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
|
|
CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA
|
Facility
|
OP
|
$4,035.20
|
|
|
Service Code
|
CPT 23655
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$393.00 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
