|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
|
OP
|
$284.00
|
|
|
Service Code
|
NDC 00574402235
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.04 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: AlohaCare Medicaid |
$142.00
|
| Rate for Payer: AlohaCare Medicare |
$88.04
|
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Devoted Health Medicare |
$96.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.80
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Humana Medicare |
$88.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$144.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$88.04
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$88.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.04
|
| Rate for Payer: University Health Alliance Commercial |
$207.01
|
|
|
BACITRACIN 500 UNIT/GRAM EYE OINTMENT [852]
|
Facility
|
IP
|
$284.00
|
|
|
Service Code
|
NDC 00574402235
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.40 |
| Max. Negotiated Rate |
$275.48 |
| Rate for Payer: Cash Price |
$170.40
|
| Rate for Payer: Health Management Network Commercial |
$241.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$255.60
|
| Rate for Payer: MDX Hawaii PPO |
$275.48
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 68001047746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 68001047746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 68001047747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 68001047747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 45802006001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT [850]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 45802006001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68001047745
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68001047745
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 68001047748
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 68001047748
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 45802006070
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
BACITRACIN 500 UNIT/GRAM TOPICAL PACKET [201691]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 45802006070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.31
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.31
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.31
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.31
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
NDC 24208055555
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.60 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
|
|
BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT [856]
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
NDC 24208055555
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.56 |
| Max. Negotiated Rate |
$73.72 |
| Rate for Payer: AlohaCare Medicaid |
$38.00
|
| Rate for Payer: AlohaCare Medicare |
$23.56
|
| Rate for Payer: Cash Price |
$45.60
|
| Rate for Payer: Devoted Health Medicare |
$25.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.20
|
| Rate for Payer: Health Management Network Commercial |
$64.60
|
| Rate for Payer: Humana Medicare |
$23.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.56
|
| Rate for Payer: MDX Hawaii PPO |
$73.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.56
|
| Rate for Payer: University Health Alliance Commercial |
$55.40
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 51672207501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
|
|
BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT [13818]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 51672207501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$16.49 |
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$5.27
|
| Rate for Payer: Cash Price |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.15
|
| Rate for Payer: Health Management Network Commercial |
$14.45
|
| Rate for Payer: Humana Medicare |
$5.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.27
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC
|
Facility
|
IP
|
$46,361.11
|
|
|
Service Code
|
MSDRG 519
|
| Min. Negotiated Rate |
$46,361.11 |
| Max. Negotiated Rate |
$46,361.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,361.11
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR
|
Facility
|
IP
|
$46,361.11
|
|
|
Service Code
|
MSDRG 518
|
| Min. Negotiated Rate |
$46,361.11 |
| Max. Negotiated Rate |
$46,361.11 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$46,361.11
|
|
|
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC
|
Facility
|
IP
|
$29,911.92
|
|
|
Service Code
|
MSDRG 520
|
| Min. Negotiated Rate |
$29,911.92 |
| Max. Negotiated Rate |
$29,911.92 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$29,911.92
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 50268010615
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| 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
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904647561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 50268010615
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904647561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
