|
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 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 5:3
|
Professional
|
Both
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442545
|
|
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: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 6:3
|
Professional
|
Both
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12442546
|
|
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: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 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
|
|
|
CLINIC:RING WITH SUPPORT AND KNOB/FOLDING 7:3
|
Professional
|
Both
|
$613.00
|
|
|
Service Code
|
HCPCS A4562
|
| Hospital Charge Code |
12441099
|
|
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: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
|
|
|
clonazePAM 0.5 mg tablet [HHSC]
|
Facility
|
IP
|
$3.94
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Health Management Network Commercial |
$3.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.55
|
| Rate for Payer: MDX Hawaii PPO |
$3.82
|
|
|
clonazePAM 0.5 mg tablet [HHSC]
|
Facility
|
OP
|
$3.94
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2501085
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$3.82 |
| Rate for Payer: AlohaCare Medicaid |
$1.97
|
| Rate for Payer: AlohaCare Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Devoted Health Medicare |
$2.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.74
|
| Rate for Payer: Health Management Network Commercial |
$3.35
|
| Rate for Payer: Humana Medicare |
$1.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.97
|
| Rate for Payer: MDX Hawaii PPO |
$3.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.97
|
| Rate for Payer: University Health Alliance Commercial |
$2.87
|
|
|
clonazePAM 1 mg tablet [HHSC]
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2500191
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.28 |
| Max. Negotiated Rate |
$4.88 |
| Rate for Payer: Cash Price |
$3.27
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Health Management Network Commercial |
$4.28
|
| Rate for Payer: Health Management Network Commercial |
$3.35
|
| Rate for Payer: Health Management Network Commercial |
$4.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.53
|
| Rate for Payer: MDX Hawaii PPO |
$3.82
|
| Rate for Payer: MDX Hawaii PPO |
$4.61
|
| Rate for Payer: MDX Hawaii PPO |
$4.88
|
|
|
clonazePAM 1 mg tablet [HHSC]
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
2500191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: AlohaCare Medicaid |
$2.38
|
| Rate for Payer: AlohaCare Medicaid |
$2.52
|
| Rate for Payer: AlohaCare Medicaid |
$1.97
|
| Rate for Payer: AlohaCare Medicare |
$2.52
|
| Rate for Payer: AlohaCare Medicare |
$2.38
|
| Rate for Payer: AlohaCare Medicare |
$1.97
|
| Rate for Payer: Cash Price |
$3.27
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cash Price |
$3.09
|
| Rate for Payer: Devoted Health Medicare |
$2.77
|
| Rate for Payer: Devoted Health Medicare |
$2.61
|
| Rate for Payer: Devoted Health Medicare |
$2.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.74
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.78
|
| Rate for Payer: Health Management Network Commercial |
$4.04
|
| Rate for Payer: Health Management Network Commercial |
$3.35
|
| Rate for Payer: Health Management Network Commercial |
$4.28
|
| Rate for Payer: Humana Medicare |
$1.97
|
| Rate for Payer: Humana Medicare |
$2.52
|
| Rate for Payer: Humana Medicare |
$2.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.52
|
| Rate for Payer: MDX Hawaii PPO |
$3.82
|
| Rate for Payer: MDX Hawaii PPO |
$4.88
|
| Rate for Payer: MDX Hawaii PPO |
$4.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.97
|
| Rate for Payer: University Health Alliance Commercial |
$3.67
|
| Rate for Payer: University Health Alliance Commercial |
$2.87
|
| Rate for Payer: University Health Alliance Commercial |
$3.46
|
|
|
cloNIDine 0.1 mg/24 hr patch [HHSC]
|
Facility
|
IP
|
$156.75
|
|
|
Service Code
|
NDC 51862045304
|
| Hospital Charge Code |
2500193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.24 |
| Max. Negotiated Rate |
$152.05 |
| Rate for Payer: Cash Price |
$101.89
|
| Rate for Payer: Health Management Network Commercial |
$133.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.07
|
| Rate for Payer: MDX Hawaii PPO |
$152.05
|
|
|
cloNIDine 0.1 mg/24 hr patch [HHSC]
|
Facility
|
IP
|
$156.75
|
|
|
Service Code
|
NDC 75907002348
|
| Hospital Charge Code |
2500193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.24 |
| Max. Negotiated Rate |
$152.05 |
| Rate for Payer: Cash Price |
$101.89
|
| Rate for Payer: Health Management Network Commercial |
$133.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.07
|
| Rate for Payer: MDX Hawaii PPO |
$152.05
|
|
|
cloNIDine 0.1 mg/24 hr patch [HHSC]
|
Facility
|
OP
|
$156.75
|
|
|
Service Code
|
NDC 75907002348
|
| Hospital Charge Code |
2500193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.38 |
| Max. Negotiated Rate |
$152.05 |
| Rate for Payer: AlohaCare Medicaid |
$78.38
|
| Rate for Payer: AlohaCare Medicare |
$78.38
|
| Rate for Payer: Cash Price |
$101.89
|
| Rate for Payer: Devoted Health Medicare |
$86.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.91
|
| Rate for Payer: Health Management Network Commercial |
$133.24
|
| Rate for Payer: Humana Medicare |
$78.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.38
|
| Rate for Payer: MDX Hawaii PPO |
$152.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.38
|
| Rate for Payer: University Health Alliance Commercial |
$114.26
|
|
|
cloNIDine 0.1 mg/24 hr patch [HHSC]
|
Facility
|
IP
|
$156.60
|
|
|
Service Code
|
NDC 00591350804
|
| Hospital Charge Code |
2500193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$133.11 |
| Max. Negotiated Rate |
$151.90 |
| Rate for Payer: Cash Price |
$101.79
|
| Rate for Payer: Health Management Network Commercial |
$133.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.94
|
| Rate for Payer: MDX Hawaii PPO |
$151.90
|
|
|
cloNIDine 0.1 mg/24 hr patch [HHSC]
|
Facility
|
OP
|
$156.75
|
|
|
Service Code
|
NDC 51862045304
|
| Hospital Charge Code |
2500193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.38 |
| Max. Negotiated Rate |
$152.05 |
| Rate for Payer: AlohaCare Medicaid |
$78.38
|
| Rate for Payer: AlohaCare Medicare |
$78.38
|
| Rate for Payer: Cash Price |
$101.89
|
| Rate for Payer: Devoted Health Medicare |
$86.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.91
|
| Rate for Payer: Health Management Network Commercial |
$133.24
|
| Rate for Payer: Humana Medicare |
$78.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.38
|
| Rate for Payer: MDX Hawaii PPO |
$152.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.38
|
| Rate for Payer: University Health Alliance Commercial |
$114.26
|
|
|
cloNIDine 0.1 mg/24 hr patch [HHSC]
|
Facility
|
OP
|
$156.60
|
|
|
Service Code
|
NDC 00591350804
|
| Hospital Charge Code |
2500193
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.30 |
| Max. Negotiated Rate |
$151.90 |
| Rate for Payer: AlohaCare Medicaid |
$78.30
|
| Rate for Payer: AlohaCare Medicare |
$78.30
|
| Rate for Payer: Cash Price |
$101.79
|
| Rate for Payer: Devoted Health Medicare |
$86.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$148.77
|
| Rate for Payer: Health Management Network Commercial |
$133.11
|
| Rate for Payer: Humana Medicare |
$78.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$140.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$79.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.30
|
| Rate for Payer: MDX Hawaii PPO |
$151.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.30
|
| Rate for Payer: University Health Alliance Commercial |
$114.15
|
|
|
cloNIDine 0.1 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
2500192
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$17.67 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.67
|
| 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
|
|
|
cloNIDine 0.1 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J0735
|
| Hospital Charge Code |
2500192
|
|
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
|
|
|
clopidogrel 75 mg tablet [HHSC]
|
Facility
|
IP
|
$42.86
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
2500196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.43 |
| Max. Negotiated Rate |
$41.57 |
| Rate for Payer: Cash Price |
$27.86
|
| Rate for Payer: Health Management Network Commercial |
$36.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.57
|
| Rate for Payer: MDX Hawaii PPO |
$41.57
|
|
|
clopidogrel 75 mg tablet [HHSC]
|
Facility
|
OP
|
$42.86
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
2500196
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$41.57 |
| Rate for Payer: AlohaCare Medicaid |
$21.43
|
| Rate for Payer: AlohaCare Medicare |
$21.43
|
| Rate for Payer: Cash Price |
$27.86
|
| Rate for Payer: Devoted Health Medicare |
$23.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.72
|
| Rate for Payer: Health Management Network Commercial |
$36.43
|
| Rate for Payer: Humana Medicare |
$21.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.43
|
| Rate for Payer: MDX Hawaii PPO |
$41.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.43
|
| Rate for Payer: University Health Alliance Commercial |
$31.24
|
|
|
Closed Elbow Dis W/o Anes TechFee
|
Facility
|
OP
|
$823.00
|
|
|
Service Code
|
HCPCS 24600
|
| Hospital Charge Code |
8022932
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$411.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$411.50
|
| Rate for Payer: AlohaCare Medicare |
$411.50
|
| Rate for Payer: Cash Price |
$534.95
|
| Rate for Payer: Cash Price |
$534.95
|
| Rate for Payer: Devoted Health Medicare |
$452.65
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$411.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$781.85
|
| Rate for Payer: Health Management Network Commercial |
$699.55
|
| Rate for Payer: Humana Medicare |
$411.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$740.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$411.50
|
| Rate for Payer: MDX Hawaii PPO |
$798.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$411.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$411.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$411.50
|
| Rate for Payer: University Health Alliance Commercial |
$599.88
|
|
