|
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 |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| 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
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 24208083060
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$67.90 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.00
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
|
|
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 |
$40.92 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$40.92
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Devoted Health Medicare |
$44.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$40.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.92
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.92
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
|
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 |
$21.70 |
| Max. Negotiated Rate |
$67.90 |
| Rate for Payer: AlohaCare Medicaid |
$35.00
|
| Rate for Payer: AlohaCare Medicare |
$21.70
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Devoted Health Medicare |
$23.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.50
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Humana Medicare |
$21.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.70
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.70
|
| 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
|
IP
|
$132.00
|
|
|
Service Code
|
NDC 61314063006
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
NDC 24208063562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.55 |
| Max. Negotiated Rate |
$293.91 |
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Health Management Network Commercial |
$257.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$272.70
|
| Rate for Payer: MDX Hawaii PPO |
$293.91
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
NDC 24208063562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.93 |
| Max. Negotiated Rate |
$293.91 |
| Rate for Payer: AlohaCare Medicaid |
$151.50
|
| Rate for Payer: AlohaCare Medicare |
$93.93
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Devoted Health Medicare |
$103.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$287.85
|
| Rate for Payer: Health Management Network Commercial |
$257.55
|
| Rate for Payer: Humana Medicare |
$93.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$272.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$154.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.93
|
| Rate for Payer: MDX Hawaii PPO |
$293.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.93
|
| Rate for Payer: University Health Alliance Commercial |
$220.86
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
NDC 64980044801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$251.60 |
| Max. Negotiated Rate |
$287.12 |
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Health Management Network Commercial |
$251.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$266.40
|
| Rate for Payer: MDX Hawaii PPO |
$287.12
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
NDC 64980044801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.76 |
| Max. Negotiated Rate |
$287.12 |
| Rate for Payer: AlohaCare Medicaid |
$148.00
|
| Rate for Payer: AlohaCare Medicare |
$91.76
|
| Rate for Payer: Cash Price |
$177.60
|
| Rate for Payer: Devoted Health Medicare |
$100.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$91.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$281.20
|
| Rate for Payer: Health Management Network Commercial |
$251.60
|
| Rate for Payer: Humana Medicare |
$91.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$266.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$150.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$91.76
|
| Rate for Payer: MDX Hawaii PPO |
$287.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$91.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$91.76
|
| Rate for Payer: University Health Alliance Commercial |
$215.75
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
NDC 24208063110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$257.55 |
| Max. Negotiated Rate |
$293.91 |
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Health Management Network Commercial |
$257.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$272.70
|
| Rate for Payer: MDX Hawaii PPO |
$293.91
|
|
|
NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
NDC 24208063110
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.93 |
| Max. Negotiated Rate |
$293.91 |
| Rate for Payer: AlohaCare Medicaid |
$151.50
|
| Rate for Payer: AlohaCare Medicare |
$93.93
|
| Rate for Payer: Cash Price |
$181.80
|
| Rate for Payer: Devoted Health Medicare |
$103.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$287.85
|
| Rate for Payer: Health Management Network Commercial |
$257.55
|
| Rate for Payer: Humana Medicare |
$93.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$272.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$154.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.93
|
| Rate for Payer: MDX Hawaii PPO |
$293.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.93
|
| Rate for Payer: University Health Alliance Commercial |
$220.86
|
|
|
NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY
|
Facility
|
IP
|
$64,422.04
|
|
|
Service Code
|
MSDRG 789
|
| Min. Negotiated Rate |
$64,422.04 |
| Max. Negotiated Rate |
$64,422.04 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$64,422.04
|
|
|
NEONATE WITH OTHER SIGNIFICANT PROBLEMS
|
Facility
|
IP
|
$4,029.34
|
|
|
Service Code
|
MSDRG 794
|
| Min. Negotiated Rate |
$4,029.34 |
| Max. Negotiated Rate |
$4,029.34 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4,029.34
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [122267]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 00641614910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [122267]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00641626501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [122267]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 00641626510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [122267]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 00641614901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
|
|
NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION [122267]
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
NDC 51754122003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
|
|
NERVEANA FACIAL
|
Facility
|
IP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.55 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
|
|
NERVEANA FACIAL
|
Facility
|
OP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.53 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: AlohaCare Medicaid |
$281.50
|
| Rate for Payer: AlohaCare Medicare |
$174.53
|
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Devoted Health Medicare |
$191.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$534.85
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Humana Medicare |
$174.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$287.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.53
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.53
|
| Rate for Payer: University Health Alliance Commercial |
$410.37
|
|
|
NERVE CONNECTOR 1.5X15 AGX115
|
Facility
|
OP
|
$3,850.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,193.50 |
| Max. Negotiated Rate |
$3,734.50 |
| Rate for Payer: AlohaCare Medicaid |
$1,925.00
|
| Rate for Payer: AlohaCare Medicare |
$1,193.50
|
| Rate for Payer: Cash Price |
$2,310.00
|
| Rate for Payer: Devoted Health Medicare |
$1,309.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,193.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,695.00
|
| Rate for Payer: Health Management Network Commercial |
$3,272.50
|
| Rate for Payer: Humana Medicare |
$1,193.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,465.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,963.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,193.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,734.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,193.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,193.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,193.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,156.00
|
|
|
NERVE CONNECTOR 1.5X15 AGX115
|
Facility
|
IP
|
$3,850.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,156.00 |
| Max. Negotiated Rate |
$3,734.50 |
| Rate for Payer: Cash Price |
$2,310.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,695.00
|
| Rate for Payer: Health Management Network Commercial |
$3,272.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,465.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,734.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,156.00
|
|
|
NERVE CONNECTOR 2X20 AG0220
|
Facility
|
IP
|
$4,406.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,467.36 |
| Max. Negotiated Rate |
$4,273.82 |
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,084.20
|
| Rate for Payer: Health Management Network Commercial |
$3,745.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,965.40
|
| Rate for Payer: MDX Hawaii PPO |
$4,273.82
|
| Rate for Payer: University Health Alliance Commercial |
$2,467.36
|
|
|
NERVE CONNECTOR 2X20 AG0220
|
Facility
|
OP
|
$4,406.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,365.86 |
| Max. Negotiated Rate |
$4,273.82 |
| Rate for Payer: AlohaCare Medicaid |
$2,203.00
|
| Rate for Payer: AlohaCare Medicare |
$1,365.86
|
| Rate for Payer: Cash Price |
$2,643.60
|
| Rate for Payer: Devoted Health Medicare |
$1,498.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,365.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,084.20
|
| Rate for Payer: Health Management Network Commercial |
$3,745.10
|
| Rate for Payer: Humana Medicare |
$1,365.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,965.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,247.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,365.86
|
| Rate for Payer: MDX Hawaii PPO |
$4,273.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,365.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,365.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,365.86
|
| Rate for Payer: University Health Alliance Commercial |
$2,467.36
|
|
|
NERVE CONNECTOR 3X15 AGX315
|
Facility
|
IP
|
$3,850.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,156.00 |
| Max. Negotiated Rate |
$3,734.50 |
| Rate for Payer: Cash Price |
$2,310.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,695.00
|
| Rate for Payer: Health Management Network Commercial |
$3,272.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,465.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,734.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,156.00
|
|
