|
NEEDLE SPINAL 25GX3.5 WHITACRE
|
Facility
|
OP
|
$68.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: AlohaCare Medicaid |
$34.00
|
| Rate for Payer: AlohaCare Medicare |
$21.08
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Devoted Health Medicare |
$23.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.60
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Humana Medicare |
$21.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.08
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.08
|
| Rate for Payer: University Health Alliance Commercial |
$49.57
|
|
|
NEEDLE SPINAL 25GX3.5 WHITACRE
|
Facility
|
IP
|
$68.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.80 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
|
|
NEEDLE SPINAL 27GX3.5 WHITACRE
|
Facility
|
IP
|
$76.00
|
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
NEEDLE SPINAL 27GX3.5 WHITACRE
|
Facility
|
OP
|
$76.00
|
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
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 |
$57.04 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: AlohaCare Medicaid |
$92.00
|
| Rate for Payer: AlohaCare Medicare |
$57.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Devoted Health Medicare |
$62.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$57.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.80
|
| Rate for Payer: Health Management Network Commercial |
$156.40
|
| Rate for Payer: Humana Medicare |
$57.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$93.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$57.04
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$57.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$57.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$57.04
|
| Rate for Payer: University Health Alliance Commercial |
$134.12
|
|
|
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: Kaiser Permanente Commercial |
$165.60
|
| Rate for Payer: MDX Hawaii PPO |
$178.48
|
|
|
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: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
|
|
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 |
$18.91 |
| Max. Negotiated Rate |
$59.17 |
| Rate for Payer: AlohaCare Medicaid |
$30.50
|
| Rate for Payer: AlohaCare Medicare |
$18.91
|
| Rate for Payer: Cash Price |
$36.60
|
| Rate for Payer: Devoted Health Medicare |
$20.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.95
|
| Rate for Payer: Health Management Network Commercial |
$51.85
|
| Rate for Payer: Humana Medicare |
$18.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$54.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.91
|
| Rate for Payer: MDX Hawaii PPO |
$59.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.91
|
| Rate for Payer: University Health Alliance Commercial |
$44.46
|
|
|
NEOMYCIN 500 MG TABLET [5472]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 00093117701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.86
|
| 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: Kaiser Permanente Commercial |
$5.40
|
| 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: Kaiser Permanente Commercial |
$112.50
|
| 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 |
$38.75 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: AlohaCare Medicaid |
$62.50
|
| Rate for Payer: AlohaCare Medicare |
$38.75
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Devoted Health Medicare |
$42.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.75
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Humana Medicare |
$38.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$112.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.75
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.75
|
| 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
|
$14.00
|
|
|
Service Code
|
NDC 45802014301
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| 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
|
OP
|
$18.00
|
|
|
Service Code
|
NDC 68001048346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$5.58
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$5.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.58
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.58
|
| 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: Kaiser Permanente Commercial |
$12.60
|
| 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
|
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: Kaiser Permanente Commercial |
$16.20
|
| 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 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: Kaiser Permanente Commercial |
$0.90
|
| 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 |
$0.31 |
| 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
|
|
|
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: Kaiser Permanente Commercial |
$0.90
|
| 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 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: Kaiser Permanente Commercial |
$0.90
|
| 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 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: Kaiser Permanente Commercial |
$0.90
|
| 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 |
$0.31 |
| 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
|
|
|
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 |
$0.31 |
| 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
|
|
|
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 |
$0.31 |
| 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
|
|
|
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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
