|
NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT 97605
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$18.49 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: AlohaCare Medicaid |
$237.02
|
| Rate for Payer: AlohaCare Medicare |
$237.02
|
| Rate for Payer: Devoted Health Medicare |
$260.72
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$296.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.02
|
| Rate for Payer: Humana Medicare |
$237.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$260.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$237.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.02
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS [5474]
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
NDC 24208079062
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$156.40 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
|
|
NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS [5474]
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
NDC 24208079062
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.84 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.80
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$115.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.84
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
| Rate for Payer: University Health Alliance Commercial |
$134.12
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
NDC 24208079535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.11 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.95
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.11
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
| Rate for Payer: University Health Alliance Commercial |
$44.46
|
|
|
NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
NDC 24208079535
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$51.85 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
|
|
NEOMYCIN 500 MG TABLET [5472]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00093117701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
NEOMYCIN 500 MG TABLET [5472]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 00093117701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT [38701]
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
NDC 24208078055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
|
|
NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT [38701]
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
NDC 24208078055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.75 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.75
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.75
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: University Health Alliance Commercial |
$91.11
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [16839]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 68001048346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [16839]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 45802014301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [16839]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 45802014301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [16839]
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
NDC 68001048346
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802014300
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904880567
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802014370
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904880567
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 47682022335
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802014300
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802014370
|
|
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
|
|
|
NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT TOP OINT PKT [82162]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 47682022335
|
|
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
|
|
|
NEOMYCIN/POLYMYXIN B/HC OTIC SUSPENSION (CORTISPORIN) (10 ML) (TAKE HOME) [4080351]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080139
|
|
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
|
|
|
NEOMYCIN/POLYMYXIN B/HC OTIC SUSPENSION (CORTISPORIN) (10 ML) (TAKE HOME) [4080351]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080139
|
|
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
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 24208083060
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$67.90 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.50
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.70
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
| Rate for Payer: University Health Alliance Commercial |
$51.02
|
|
|
NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS [10708]
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
NDC 61314063006
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.32 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
