|
clindamycin 75 mg/5 mL 100ml [HHSC]
|
Facility
|
IP
|
$316.29
|
|
|
Service Code
|
NDC 65862059601
|
| Hospital Charge Code |
2500188
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$268.85 |
| Max. Negotiated Rate |
$306.80 |
| Rate for Payer: Cash Price |
$205.59
|
| Rate for Payer: Health Management Network Commercial |
$268.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$284.66
|
| Rate for Payer: MDX Hawaii PPO |
$306.80
|
|
|
clindamycin 900 mg/50 mL-d5w premix [HHSC]
|
Facility
|
IP
|
$93.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2500189
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$79.82 |
| Max. Negotiated Rate |
$91.09 |
| Rate for Payer: Cash Price |
$61.04
|
| Rate for Payer: Cash Price |
$54.35
|
| Rate for Payer: Health Management Network Commercial |
$71.07
|
| Rate for Payer: Health Management Network Commercial |
$79.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.52
|
| Rate for Payer: MDX Hawaii PPO |
$91.09
|
| Rate for Payer: MDX Hawaii PPO |
$81.10
|
|
|
clindamycin 900 mg/50 mL-d5w premix [HHSC]
|
Facility
|
OP
|
$93.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2500189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.95 |
| Max. Negotiated Rate |
$91.09 |
| Rate for Payer: AlohaCare Medicaid |
$46.95
|
| Rate for Payer: AlohaCare Medicaid |
$41.80
|
| Rate for Payer: AlohaCare Medicare |
$46.95
|
| Rate for Payer: AlohaCare Medicare |
$41.80
|
| Rate for Payer: Cash Price |
$54.35
|
| Rate for Payer: Cash Price |
$61.04
|
| Rate for Payer: Devoted Health Medicare |
$45.99
|
| Rate for Payer: Devoted Health Medicare |
$51.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$89.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.43
|
| Rate for Payer: Health Management Network Commercial |
$79.82
|
| Rate for Payer: Health Management Network Commercial |
$71.07
|
| Rate for Payer: Humana Medicare |
$41.80
|
| Rate for Payer: Humana Medicare |
$46.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.80
|
| Rate for Payer: MDX Hawaii PPO |
$91.09
|
| Rate for Payer: MDX Hawaii PPO |
$81.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.95
|
| Rate for Payer: University Health Alliance Commercial |
$60.94
|
| Rate for Payer: University Health Alliance Commercial |
$68.45
|
|
|
clindamycin 900 mg/6 mL vial [HHSC]
|
Facility
|
OP
|
$31.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2501103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$30.74 |
| Rate for Payer: AlohaCare Medicaid |
$15.85
|
| Rate for Payer: AlohaCare Medicaid |
$14.22
|
| Rate for Payer: AlohaCare Medicare |
$15.85
|
| Rate for Payer: AlohaCare Medicare |
$14.22
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Cash Price |
$20.60
|
| Rate for Payer: Devoted Health Medicare |
$15.65
|
| Rate for Payer: Devoted Health Medicare |
$17.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.03
|
| Rate for Payer: Health Management Network Commercial |
$26.94
|
| Rate for Payer: Health Management Network Commercial |
$24.18
|
| Rate for Payer: Humana Medicare |
$14.22
|
| Rate for Payer: Humana Medicare |
$15.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.22
|
| Rate for Payer: MDX Hawaii PPO |
$30.74
|
| Rate for Payer: MDX Hawaii PPO |
$27.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.85
|
| Rate for Payer: University Health Alliance Commercial |
$20.74
|
| Rate for Payer: University Health Alliance Commercial |
$23.10
|
|
|
clindamycin 900 mg/6 mL vial [HHSC]
|
Facility
|
IP
|
$31.69
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2501103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.94 |
| Max. Negotiated Rate |
$30.74 |
| Rate for Payer: Cash Price |
$20.60
|
| Rate for Payer: Cash Price |
$18.49
|
| Rate for Payer: Health Management Network Commercial |
$24.18
|
| Rate for Payer: Health Management Network Commercial |
$26.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.52
|
| Rate for Payer: MDX Hawaii PPO |
$30.74
|
| Rate for Payer: MDX Hawaii PPO |
$27.60
|
|
|
CLINIC:PESSARY, GELLHORN FLEX 1/2 (64 MM)
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441101
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.50 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: AlohaCare Medicaid |
$306.50
|
| Rate for Payer: AlohaCare Medicare |
$306.50
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Devoted Health Medicare |
$337.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$306.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$582.35
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Humana Medicare |
$306.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$312.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$306.50
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$306.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$306.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$306.50
|
| Rate for Payer: University Health Alliance Commercial |
$446.82
|
|
|
CLINIC:PESSARY, GELLHORN FLEX 1/2 (64 MM)
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441101
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.05 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
|
|
CLINIC:PESSARY MILEX RING WITH KNOB/FOLDING
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442547
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$531.25 |
| Max. Negotiated Rate |
$606.25 |
| Rate for Payer: Cash Price |
$406.25
|
| Rate for Payer: Health Management Network Commercial |
$531.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$562.50
|
| Rate for Payer: MDX Hawaii PPO |
$606.25
|
|
|
CLINIC:PESSARY MILEX RING WITH KNOB/FOLDING
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442547
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$312.50 |
| Max. Negotiated Rate |
$606.25 |
| Rate for Payer: AlohaCare Medicaid |
$312.50
|
| Rate for Payer: AlohaCare Medicare |
$312.50
|
| Rate for Payer: Cash Price |
$406.25
|
| Rate for Payer: Devoted Health Medicare |
$343.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$312.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$593.75
|
| Rate for Payer: Health Management Network Commercial |
$531.25
|
| Rate for Payer: Humana Medicare |
$312.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$562.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$318.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$312.50
|
| Rate for Payer: MDX Hawaii PPO |
$606.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$312.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$312.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$312.50
|
| Rate for Payer: University Health Alliance Commercial |
$455.56
|
|
|
CLINIC:RING, MILEX W/SUPPORT/FOLDING PESSARY SZ 3
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$531.25 |
| Max. Negotiated Rate |
$606.25 |
| Rate for Payer: Cash Price |
$406.25
|
| Rate for Payer: Health Management Network Commercial |
$531.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$562.50
|
| Rate for Payer: MDX Hawaii PPO |
$606.25
|
|
|
CLINIC:RING, MILEX W/SUPPORT/FOLDING PESSARY SZ 3
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$312.50 |
| Max. Negotiated Rate |
$606.25 |
| Rate for Payer: AlohaCare Medicaid |
$312.50
|
| Rate for Payer: AlohaCare Medicare |
$312.50
|
| Rate for Payer: Cash Price |
$406.25
|
| Rate for Payer: Devoted Health Medicare |
$343.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$312.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$593.75
|
| Rate for Payer: Health Management Network Commercial |
$531.25
|
| Rate for Payer: Humana Medicare |
$312.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$562.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$318.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$312.50
|
| Rate for Payer: MDX Hawaii PPO |
$606.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$312.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$312.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$312.50
|
| Rate for Payer: University Health Alliance Commercial |
$455.56
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 5:3
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442545
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.05 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 5:3
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442545
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.50 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: AlohaCare Medicaid |
$306.50
|
| Rate for Payer: AlohaCare Medicare |
$306.50
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Devoted Health Medicare |
$337.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$306.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$582.35
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Humana Medicare |
$306.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$312.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$306.50
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$306.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$306.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$306.50
|
| Rate for Payer: University Health Alliance Commercial |
$446.82
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 6:3
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442546
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.05 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 6:3
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442546
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.50 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: AlohaCare Medicaid |
$306.50
|
| Rate for Payer: AlohaCare Medicare |
$306.50
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Devoted Health Medicare |
$337.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$306.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$582.35
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Humana Medicare |
$306.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$312.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$306.50
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$306.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$306.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$306.50
|
| Rate for Payer: University Health Alliance Commercial |
$446.82
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 7:3
|
Facility
|
IP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441099
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.05 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 7:3
|
Facility
|
OP
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441099
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.50 |
| Max. Negotiated Rate |
$594.61 |
| Rate for Payer: AlohaCare Medicaid |
$306.50
|
| Rate for Payer: AlohaCare Medicare |
$306.50
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Devoted Health Medicare |
$337.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$306.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$582.35
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
| Rate for Payer: Humana Medicare |
$306.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$551.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$312.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$306.50
|
| Rate for Payer: MDX Hawaii PPO |
$594.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$306.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$306.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$306.50
|
| Rate for Payer: University Health Alliance Commercial |
$446.82
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
IP
|
$1,046.00
|
|
|
Service Code
|
NDC 21922001606
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$889.10 |
| Max. Negotiated Rate |
$1,014.62 |
| Rate for Payer: Cash Price |
$679.90
|
| Rate for Payer: Health Management Network Commercial |
$889.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$941.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,014.62
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
IP
|
$1,045.98
|
|
|
Service Code
|
NDC 51672125806
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$889.08 |
| Max. Negotiated Rate |
$1,014.60 |
| Rate for Payer: Cash Price |
$679.89
|
| Rate for Payer: Health Management Network Commercial |
$889.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$941.38
|
| Rate for Payer: MDX Hawaii PPO |
$1,014.60
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
OP
|
$1,046.00
|
|
|
Service Code
|
NDC 21922001606
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.00 |
| Max. Negotiated Rate |
$1,014.62 |
| Rate for Payer: AlohaCare Medicaid |
$523.00
|
| Rate for Payer: AlohaCare Medicare |
$523.00
|
| Rate for Payer: Cash Price |
$679.90
|
| Rate for Payer: Devoted Health Medicare |
$575.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$523.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$993.70
|
| Rate for Payer: Health Management Network Commercial |
$889.10
|
| Rate for Payer: Humana Medicare |
$523.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$941.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$533.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$523.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,014.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$523.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$523.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$627.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$523.00
|
| Rate for Payer: University Health Alliance Commercial |
$762.43
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
OP
|
$1,048.09
|
|
|
Service Code
|
NDC 13668056904
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$524.04 |
| Max. Negotiated Rate |
$1,016.65 |
| Rate for Payer: AlohaCare Medicaid |
$524.04
|
| Rate for Payer: AlohaCare Medicare |
$524.04
|
| Rate for Payer: Cash Price |
$681.26
|
| Rate for Payer: Devoted Health Medicare |
$576.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$524.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$995.69
|
| Rate for Payer: Health Management Network Commercial |
$890.88
|
| Rate for Payer: Humana Medicare |
$524.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$943.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$534.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$524.04
|
| Rate for Payer: MDX Hawaii PPO |
$1,016.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$524.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$524.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$628.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$524.04
|
| Rate for Payer: University Health Alliance Commercial |
$763.95
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
OP
|
$1,046.00
|
|
|
Service Code
|
NDC 69238153204
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$523.00 |
| Max. Negotiated Rate |
$1,014.62 |
| Rate for Payer: AlohaCare Medicaid |
$523.00
|
| Rate for Payer: AlohaCare Medicare |
$523.00
|
| Rate for Payer: Cash Price |
$679.90
|
| Rate for Payer: Devoted Health Medicare |
$575.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$523.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$993.70
|
| Rate for Payer: Health Management Network Commercial |
$889.10
|
| Rate for Payer: Humana Medicare |
$523.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$941.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$533.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$523.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,014.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$523.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$523.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$627.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$523.00
|
| Rate for Payer: University Health Alliance Commercial |
$762.43
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
IP
|
$1,046.00
|
|
|
Service Code
|
NDC 69238153204
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$889.10 |
| Max. Negotiated Rate |
$1,014.62 |
| Rate for Payer: Cash Price |
$679.90
|
| Rate for Payer: Health Management Network Commercial |
$889.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$941.40
|
| Rate for Payer: MDX Hawaii PPO |
$1,014.62
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
OP
|
$1,045.98
|
|
|
Service Code
|
NDC 51672125806
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$522.99 |
| Max. Negotiated Rate |
$1,014.60 |
| Rate for Payer: AlohaCare Medicaid |
$522.99
|
| Rate for Payer: AlohaCare Medicare |
$522.99
|
| Rate for Payer: Cash Price |
$679.89
|
| Rate for Payer: Devoted Health Medicare |
$575.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$522.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$993.68
|
| Rate for Payer: Health Management Network Commercial |
$889.08
|
| Rate for Payer: Humana Medicare |
$522.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$941.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$533.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$522.99
|
| Rate for Payer: MDX Hawaii PPO |
$1,014.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$522.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$522.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$627.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$522.99
|
| Rate for Payer: University Health Alliance Commercial |
$762.41
|
|
|
clobetasol 0.05% topical cream 45g [HHSC]
|
Facility
|
IP
|
$1,048.09
|
|
|
Service Code
|
NDC 13668056904
|
| Hospital Charge Code |
2500190
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$890.88 |
| Max. Negotiated Rate |
$1,016.65 |
| Rate for Payer: Cash Price |
$681.26
|
| Rate for Payer: Health Management Network Commercial |
$890.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$943.28
|
| Rate for Payer: MDX Hawaii PPO |
$1,016.65
|
|
