|
CLOSURE OF GASTROCOLIC FISTULA
|
Facility
|
OP
|
$14,395.00
|
|
|
Service Code
|
CPT 43880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$872.30 |
| Max. Negotiated Rate |
$14,395.00 |
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,900.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,395.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,695.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$872.30
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00054414622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
CLOTRIMAZOLE 10 MG TROCHE [9644]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00054414622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 61269022041
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 61269022063
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 61269022041
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.67 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
CLOTRIMAZOLE 1 % VAGINAL CREAM [1769]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 61269022063
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.67 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
CLOTRIMAZOLE/BETAMETHASONE 1-0.05% CREAM (LOTRISONE) (15 GRAM) (TAKE HOME) [4080372]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080160
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
CLOTRIMAZOLE/BETAMETHASONE 1-0.05% CREAM (LOTRISONE) (15 GRAM) (TAKE HOME) [4080372]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080160
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$293.00
|
|
|
Service Code
|
NDC 00472037945
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.43 |
| Max. Negotiated Rate |
$284.21 |
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$278.35
|
| Rate for Payer: Health Management Network Commercial |
$249.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$149.43
|
| Rate for Payer: MDX Hawaii PPO |
$284.21
|
| Rate for Payer: University Health Alliance Commercial |
$213.57
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$197.00
|
|
|
Service Code
|
NDC 68462029817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.47 |
| Max. Negotiated Rate |
$191.09 |
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$187.15
|
| Rate for Payer: Health Management Network Commercial |
$167.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$124.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$100.47
|
| Rate for Payer: MDX Hawaii PPO |
$191.09
|
| Rate for Payer: University Health Alliance Commercial |
$143.59
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$153.00
|
|
|
Service Code
|
NDC 00168025846
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.05 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
NDC 00472037915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$115.60 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$293.00
|
|
|
Service Code
|
NDC 00472037945
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$249.05 |
| Max. Negotiated Rate |
$284.21 |
| Rate for Payer: Cash Price |
$175.80
|
| Rate for Payer: Health Management Network Commercial |
$249.05
|
| Rate for Payer: MDX Hawaii PPO |
$284.21
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
NDC 00168025815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.35 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
IP
|
$197.00
|
|
|
Service Code
|
NDC 68462029817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$167.45 |
| Max. Negotiated Rate |
$191.09 |
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Health Management Network Commercial |
$167.45
|
| Rate for Payer: MDX Hawaii PPO |
$191.09
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$71.00
|
|
|
Service Code
|
NDC 00168025815
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.21 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$67.45
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.21
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
| Rate for Payer: University Health Alliance Commercial |
$51.75
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
NDC 00472037915
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.36 |
| Max. Negotiated Rate |
$131.92 |
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$129.20
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.36
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: University Health Alliance Commercial |
$99.13
|
|
|
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM [29424]
|
Facility
|
OP
|
$153.00
|
|
|
Service Code
|
NDC 00168025846
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.03 |
| Max. Negotiated Rate |
$148.41 |
| Rate for Payer: Cash Price |
$91.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$145.35
|
| Rate for Payer: Health Management Network Commercial |
$130.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.39
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.03
|
| Rate for Payer: MDX Hawaii PPO |
$148.41
|
| Rate for Payer: University Health Alliance Commercial |
$111.52
|
|
|
CLOZAPINE 100 MG TABLET [9647]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 60687041501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
CLOZAPINE 100 MG TABLET [9647]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 60687041501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
CLOZAPINE 100 MG TABLET [9647]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 60687041511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
CLOZAPINE 100 MG TABLET [9647]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 60687041511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687040411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
CLOZAPINE 25 MG TABLET [9648]
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
NDC 60687040401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
