Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$336.00

Service Code	NDC 00574200802
Hospital Revenue Code	637
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$325.92
Rate for Payer: AlohaCare Medicaid	$168.00
Rate for Payer: AlohaCare Medicare	$255.36
Rate for Payer: Cash Price	$201.60
Rate for Payer: Devoted Health Medicare	$282.24
Rate for Payer: Hawaii Medical Service Association Medicare	$255.36
Rate for Payer: Hawaii Western Management Group Commercial	$319.20
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Humana Medicare	$255.36
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: Kaiser Permanente Medicaid	$171.36
Rate for Payer: Kaiser Permanente Medicare	$255.36
Rate for Payer: MDX Hawaii PPO	$325.92
Rate for Payer: Ohana Health Plan Medicaid	$255.36
Rate for Payer: Ohana Health Plan Medicare	$255.36
Rate for Payer: UnitedHealthcare Medicare	$255.36
Rate for Payer: University Health Alliance Commercial	$244.91

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$336.00

Service Code	NDC 00574200802
Hospital Revenue Code	250
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$325.92
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Management Network Commercial	$285.60
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: MDX Hawaii PPO	$325.92

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$77.00

Service Code	NDC 68308015215
Hospital Revenue Code	250
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$74.69
Rate for Payer: Cash Price	$46.20
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: MDX Hawaii PPO	$74.69

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$97.00

Service Code	NDC 00574200815
Hospital Revenue Code	637
Min. Negotiated Rate	$48.50
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$73.72
Rate for Payer: Cash Price	$58.20
Rate for Payer: Devoted Health Medicare	$81.48
Rate for Payer: Hawaii Medical Service Association Medicare	$73.72
Rate for Payer: Hawaii Western Management Group Commercial	$92.15
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$73.72
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$73.72
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$73.72
Rate for Payer: Ohana Health Plan Medicare	$73.72
Rate for Payer: UnitedHealthcare Medicare	$73.72
Rate for Payer: University Health Alliance Commercial	$70.70

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$77.00

Service Code	NDC 68308015215
Hospital Revenue Code	637
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$74.69
Rate for Payer: AlohaCare Medicaid	$38.50
Rate for Payer: AlohaCare Medicare	$58.52
Rate for Payer: Cash Price	$46.20
Rate for Payer: Devoted Health Medicare	$64.68
Rate for Payer: Hawaii Medical Service Association Medicare	$58.52
Rate for Payer: Hawaii Western Management Group Commercial	$73.15
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Humana Medicare	$58.52
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$39.27
Rate for Payer: Kaiser Permanente Medicare	$58.52
Rate for Payer: MDX Hawaii PPO	$74.69
Rate for Payer: Ohana Health Plan Medicaid	$58.52
Rate for Payer: Ohana Health Plan Medicare	$58.52
Rate for Payer: UnitedHealthcare Medicare	$58.52
Rate for Payer: University Health Alliance Commercial	$56.13

NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER [39136]

Facility

$97.00

Service Code	NDC 00574200815
Hospital Revenue Code	250
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$58.20
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$8.00

Service Code	NDC 60687080017
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$4.00

Service Code	NDC 66689003799
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.88
Rate for Payer: AlohaCare Medicaid	$2.00
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$2.40
Rate for Payer: Devoted Health Medicare	$3.36
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$2.92

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$8.00

Service Code	NDC 60687080040
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$8.00

Service Code	NDC 60687080017
Hospital Revenue Code	637
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.76
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$6.08
Rate for Payer: Cash Price	$4.80
Rate for Payer: Devoted Health Medicare	$6.72
Rate for Payer: Hawaii Medical Service Association Medicare	$6.08
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Humana Medicare	$6.08
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicare	$6.08
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: Ohana Health Plan Medicaid	$6.08
Rate for Payer: Ohana Health Plan Medicare	$6.08
Rate for Payer: UnitedHealthcare Medicare	$6.08
Rate for Payer: University Health Alliance Commercial	$5.83

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$51.00

Service Code	NDC 66689000802
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$51.00

Service Code	NDC 69315050460
Hospital Revenue Code	637
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$38.76
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$38.76
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$38.76
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$38.76
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$38.76
Rate for Payer: Ohana Health Plan Medicare	$38.76
Rate for Payer: UnitedHealthcare Medicare	$38.76
Rate for Payer: University Health Alliance Commercial	$37.17

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$51.00

Service Code	NDC 69315050460
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$60.00

Service Code	NDC 60432053760
Hospital Revenue Code	250
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$58.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: MDX Hawaii PPO	$58.20

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$51.00

Service Code	NDC 66689000802
Hospital Revenue Code	637
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$38.76
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$38.76
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$38.76
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$38.76
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$38.76
Rate for Payer: Ohana Health Plan Medicare	$38.76
Rate for Payer: UnitedHealthcare Medicare	$38.76
Rate for Payer: University Health Alliance Commercial	$37.17

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$51.00

Service Code	NDC 00121086802
Hospital Revenue Code	637
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$38.76
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$38.76
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$38.76
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$38.76
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$38.76
Rate for Payer: Ohana Health Plan Medicare	$38.76
Rate for Payer: UnitedHealthcare Medicare	$38.76
Rate for Payer: University Health Alliance Commercial	$37.17

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$8.00

Service Code	NDC 60687080040
Hospital Revenue Code	250
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$7.20
Rate for Payer: MDX Hawaii PPO	$7.76

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$51.00

Service Code	NDC 00121086802
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$60.00

Service Code	NDC 60432053760
Hospital Revenue Code	637
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$58.20
Rate for Payer: AlohaCare Medicaid	$30.00
Rate for Payer: AlohaCare Medicare	$45.60
Rate for Payer: Cash Price	$36.00
Rate for Payer: Devoted Health Medicare	$50.40
Rate for Payer: Hawaii Medical Service Association Medicare	$45.60
Rate for Payer: Hawaii Western Management Group Commercial	$57.00
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Humana Medicare	$45.60
Rate for Payer: Kaiser Permanente Commercial	$54.00
Rate for Payer: Kaiser Permanente Medicaid	$30.60
Rate for Payer: Kaiser Permanente Medicare	$45.60
Rate for Payer: MDX Hawaii PPO	$58.20
Rate for Payer: Ohana Health Plan Medicaid	$45.60
Rate for Payer: Ohana Health Plan Medicare	$45.60
Rate for Payer: UnitedHealthcare Medicare	$45.60
Rate for Payer: University Health Alliance Commercial	$43.73

NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION [5751]

Facility

$4.00

Service Code	NDC 66689003799
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$3.60
Rate for Payer: MDX Hawaii PPO	$3.88

NYSTATIN SUSPENSION (MYCOSTATIN) 100000 UNIT/1 ML (60 ML) (TAKE HOME) [4080382]

Facility

$15.00

Service Code	NDC 00004080170
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: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

NYSTATIN SUSPENSION (MYCOSTATIN) 100000 UNIT/1 ML (60 ML) (TAKE HOME) [4080382]

Facility

$15.00

Service Code	NDC 00004080170
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$88.00

Service Code	NDC 45802088014
Hospital Revenue Code	637
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$85.36
Rate for Payer: AlohaCare Medicaid	$44.00
Rate for Payer: AlohaCare Medicare	$66.88
Rate for Payer: Cash Price	$52.80
Rate for Payer: Devoted Health Medicare	$73.92
Rate for Payer: Hawaii Medical Service Association Medicare	$66.88
Rate for Payer: Hawaii Western Management Group Commercial	$83.60
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Humana Medicare	$66.88
Rate for Payer: Kaiser Permanente Commercial	$79.20
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: Kaiser Permanente Medicare	$66.88
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: Ohana Health Plan Medicaid	$66.88
Rate for Payer: Ohana Health Plan Medicare	$66.88
Rate for Payer: UnitedHealthcare Medicare	$66.88
Rate for Payer: University Health Alliance Commercial	$64.14

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM [5754]

Facility

$88.00

Service Code	NDC 45802088014
Hospital Revenue Code	250
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$79.20
Rate for Payer: MDX Hawaii PPO	$85.36

NYSTATIN-TRIAMCINOLONE 100,000 UNIT/GRAM-0.1 % TOPICAL OINTMENT [5755]

Facility

$146.00

Service Code	NDC 62332058515
Hospital Revenue Code	250
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$87.60
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: MDX Hawaii PPO	$141.62

Know your out-of-pocket cost for care.

All Charges