|
clindamycin 300 mg capsule [HHSC]
|
Facility
|
OP
|
$7.91
|
|
|
Service Code
|
NDC 50268018515
|
| Hospital Charge Code |
2500186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$7.67 |
| Rate for Payer: AlohaCare Medicaid |
$3.96
|
| Rate for Payer: AlohaCare Medicare |
$3.96
|
| Rate for Payer: Cash Price |
$5.14
|
| Rate for Payer: Devoted Health Medicare |
$4.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.51
|
| Rate for Payer: Health Management Network Commercial |
$6.72
|
| Rate for Payer: Humana Medicare |
$3.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.96
|
| Rate for Payer: MDX Hawaii PPO |
$7.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.96
|
| Rate for Payer: University Health Alliance Commercial |
$5.77
|
|
|
clindamycin 300 mg capsule [HHSC]
|
Facility
|
IP
|
$3.06
|
|
|
Service Code
|
NDC 59762501002
|
| Hospital Charge Code |
2500186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.60 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Health Management Network Commercial |
$2.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.75
|
| Rate for Payer: MDX Hawaii PPO |
$2.97
|
|
|
clindamycin 300 mg capsule [HHSC]
|
Facility
|
IP
|
$7.22
|
|
|
Service Code
|
NDC 68084024401
|
| Hospital Charge Code |
2500186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Cash Price |
$4.69
|
| Rate for Payer: Health Management Network Commercial |
$6.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.50
|
| Rate for Payer: MDX Hawaii PPO |
$7.00
|
|
|
clindamycin 300 mg capsule [HHSC]
|
Facility
|
IP
|
$20.67
|
|
|
Service Code
|
NDC 63304069301
|
| Hospital Charge Code |
2500186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.57 |
| Max. Negotiated Rate |
$20.05 |
| Rate for Payer: Cash Price |
$13.44
|
| Rate for Payer: Health Management Network Commercial |
$17.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.60
|
| Rate for Payer: MDX Hawaii PPO |
$20.05
|
|
|
clindamycin 300 mg capsule [HHSC]
|
Facility
|
OP
|
$3.06
|
|
|
Service Code
|
NDC 59762501002
|
| Hospital Charge Code |
2500186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.97 |
| Rate for Payer: AlohaCare Medicaid |
$1.53
|
| Rate for Payer: AlohaCare Medicare |
$1.53
|
| Rate for Payer: Cash Price |
$1.99
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.91
|
| Rate for Payer: Health Management Network Commercial |
$2.60
|
| Rate for Payer: Humana Medicare |
$1.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.53
|
| Rate for Payer: University Health Alliance Commercial |
$2.23
|
|
|
clindamycin 300 mg capsule [HHSC]
|
Facility
|
OP
|
$7.22
|
|
|
Service Code
|
NDC 68084024401
|
| Hospital Charge Code |
2500186
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: AlohaCare Medicaid |
$3.61
|
| Rate for Payer: AlohaCare Medicare |
$3.61
|
| Rate for Payer: Cash Price |
$4.69
|
| Rate for Payer: Devoted Health Medicare |
$3.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.86
|
| Rate for Payer: Health Management Network Commercial |
$6.14
|
| Rate for Payer: Humana Medicare |
$3.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.61
|
| Rate for Payer: MDX Hawaii PPO |
$7.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.61
|
| Rate for Payer: University Health Alliance Commercial |
$5.26
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
IP
|
$80.18
|
|
|
Service Code
|
NDC 00781328909
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$68.15 |
| Max. Negotiated Rate |
$77.77 |
| Rate for Payer: Cash Price |
$52.12
|
| Rate for Payer: Health Management Network Commercial |
$68.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.16
|
| Rate for Payer: MDX Hawaii PPO |
$77.77
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
OP
|
$105.62
|
|
|
Service Code
|
NDC 00009337502
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$102.45 |
| Rate for Payer: AlohaCare Medicaid |
$52.81
|
| Rate for Payer: AlohaCare Medicare |
$52.81
|
| Rate for Payer: Cash Price |
$68.65
|
| Rate for Payer: Devoted Health Medicare |
$58.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.34
|
| Rate for Payer: Health Management Network Commercial |
$89.78
|
| Rate for Payer: Humana Medicare |
$52.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.81
|
| Rate for Payer: MDX Hawaii PPO |
$102.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.81
|
| Rate for Payer: University Health Alliance Commercial |
$76.99
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
OP
|
$71.72
|
|
|
Service Code
|
NDC 00338361224
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.86 |
| Max. Negotiated Rate |
$69.57 |
| Rate for Payer: AlohaCare Medicaid |
$35.86
|
| Rate for Payer: AlohaCare Medicare |
$35.86
|
| Rate for Payer: Cash Price |
$46.62
|
| Rate for Payer: Devoted Health Medicare |
$39.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$68.13
|
| Rate for Payer: Health Management Network Commercial |
$60.96
|
| Rate for Payer: Humana Medicare |
$35.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$36.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.86
|
| Rate for Payer: MDX Hawaii PPO |
$69.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.86
|
| Rate for Payer: University Health Alliance Commercial |
$52.28
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
IP
|
$105.62
|
|
|
Service Code
|
NDC 00009337502
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.78 |
| Max. Negotiated Rate |
$102.45 |
| Rate for Payer: Cash Price |
$68.65
|
| Rate for Payer: Health Management Network Commercial |
$89.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.06
|
| Rate for Payer: MDX Hawaii PPO |
$102.45
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
OP
|
$80.18
|
|
|
Service Code
|
NDC 00781328909
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.09 |
| Max. Negotiated Rate |
$77.77 |
| Rate for Payer: AlohaCare Medicaid |
$40.09
|
| Rate for Payer: AlohaCare Medicare |
$40.09
|
| Rate for Payer: Cash Price |
$52.12
|
| Rate for Payer: Devoted Health Medicare |
$44.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.17
|
| Rate for Payer: Health Management Network Commercial |
$68.15
|
| Rate for Payer: Humana Medicare |
$40.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.09
|
| Rate for Payer: MDX Hawaii PPO |
$77.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.09
|
| Rate for Payer: University Health Alliance Commercial |
$58.44
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
IP
|
$71.72
|
|
|
Service Code
|
NDC 00338361224
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$69.57 |
| Rate for Payer: Cash Price |
$46.62
|
| Rate for Payer: Health Management Network Commercial |
$60.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$64.55
|
| Rate for Payer: MDX Hawaii PPO |
$69.57
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
OP
|
$57.59
|
|
|
Service Code
|
NDC 00781922109
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$55.86 |
| Rate for Payer: AlohaCare Medicaid |
$28.80
|
| Rate for Payer: AlohaCare Medicare |
$28.80
|
| Rate for Payer: Cash Price |
$37.43
|
| Rate for Payer: Devoted Health Medicare |
$31.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$54.71
|
| Rate for Payer: Health Management Network Commercial |
$48.95
|
| Rate for Payer: Humana Medicare |
$28.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.80
|
| Rate for Payer: MDX Hawaii PPO |
$55.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.80
|
| Rate for Payer: University Health Alliance Commercial |
$41.98
|
|
|
clindamycin 600 mg/50 mL-d5w premix [HHSC]
|
Facility
|
IP
|
$57.59
|
|
|
Service Code
|
NDC 00781922109
|
| Hospital Charge Code |
2500187
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.95 |
| Max. Negotiated Rate |
$55.86 |
| Rate for Payer: Cash Price |
$37.43
|
| Rate for Payer: Health Management Network Commercial |
$48.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.83
|
| Rate for Payer: MDX Hawaii PPO |
$55.86
|
|
|
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/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/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
|
|
|
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
|
|
|
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, GELLHORN FLEX 1/2 (64 MM)
|
Professional
|
Both
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441101
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.45 |
| Max. Negotiated Rate |
$521.05 |
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Cash Price |
$398.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.45
|
| Rate for Payer: Health Management Network Commercial |
$521.05
|
|
|
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
|
Professional
|
Both
|
$625.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442547
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.45 |
| Max. Negotiated Rate |
$531.25 |
| Rate for Payer: Cash Price |
$406.25
|
| Rate for Payer: Cash Price |
$406.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.45
|
| Rate for Payer: Health Management Network Commercial |
$531.25
|
|
|
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
|
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
|
|
