|
NEEDLE YUEH CENTESIS DISP 5FR/7CM (XR/MAMMO)
|
Facility
|
OP
|
$133.00
|
|
| Hospital Charge Code |
8890000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: AlohaCare Medicaid |
$66.50
|
| Rate for Payer: AlohaCare Medicare |
$66.50
|
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Devoted Health Medicare |
$73.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$126.35
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Humana Medicare |
$66.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.50
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.50
|
| Rate for Payer: University Health Alliance Commercial |
$96.94
|
|
|
NEEDLE YUEH CENTESIS DISP 5FR/7CM (XR/MAMMO)
|
Facility
|
IP
|
$133.00
|
|
| Hospital Charge Code |
8890000
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$113.05 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
|
|
NEEDLE YUEH CENTESIS DISP CATH 5FR/10CM (CT)
|
Facility
|
IP
|
$133.00
|
|
| Hospital Charge Code |
8889567
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$113.05 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
|
|
NEEDLE YUEH CENTESIS DISP CATH 5FR/10CM (CT)
|
Facility
|
OP
|
$133.00
|
|
| Hospital Charge Code |
8889567
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: AlohaCare Medicaid |
$66.50
|
| Rate for Payer: AlohaCare Medicare |
$66.50
|
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Devoted Health Medicare |
$73.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$126.35
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Humana Medicare |
$66.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.50
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.50
|
| Rate for Payer: University Health Alliance Commercial |
$96.94
|
|
|
NEEDLE YUEH CENTESIS DISP CATH 5FR/10CM (US)
|
Facility
|
OP
|
$137.00
|
|
| Hospital Charge Code |
8889566
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.50 |
| Max. Negotiated Rate |
$132.89 |
| Rate for Payer: AlohaCare Medicaid |
$68.50
|
| Rate for Payer: AlohaCare Medicare |
$68.50
|
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Devoted Health Medicare |
$75.35
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$130.15
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Humana Medicare |
$68.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.50
|
| Rate for Payer: MDX Hawaii PPO |
$132.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.50
|
| Rate for Payer: University Health Alliance Commercial |
$99.86
|
|
|
NEEDLE YUEH CENTESIS DISP CATH 5FR/10CM (US)
|
Facility
|
IP
|
$137.00
|
|
| Hospital Charge Code |
8889566
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.45 |
| Max. Negotiated Rate |
$132.89 |
| Rate for Payer: Cash Price |
$89.05
|
| Rate for Payer: Health Management Network Commercial |
$116.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.30
|
| Rate for Payer: MDX Hawaii PPO |
$132.89
|
|
|
NEEDLE YUEH CENTESIS DISP CATH 5FR/10CM (XR/MAMMO)
|
Facility
|
OP
|
$133.00
|
|
| Hospital Charge Code |
8889997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: AlohaCare Medicaid |
$66.50
|
| Rate for Payer: AlohaCare Medicare |
$66.50
|
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Devoted Health Medicare |
$73.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$126.35
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Humana Medicare |
$66.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.50
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.50
|
| Rate for Payer: University Health Alliance Commercial |
$96.94
|
|
|
NEEDLE YUEH CENTESIS DISP CATH 5FR/10CM (XR/MAMMO)
|
Facility
|
IP
|
$133.00
|
|
| Hospital Charge Code |
8889997
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$113.05 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
|
|
Negative Pressure Wound Tx < 50 cm
|
Facility
|
IP
|
$396.00
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
12725160
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$336.60 |
| Max. Negotiated Rate |
$384.12 |
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Health Management Network Commercial |
$336.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$356.40
|
| Rate for Payer: MDX Hawaii PPO |
$384.12
|
|
|
Negative Pressure Wound Tx < 50 cm
|
Facility
|
OP
|
$396.00
|
|
|
Service Code
|
HCPCS 97605
|
| Hospital Charge Code |
12725160
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$18.49 |
| Max. Negotiated Rate |
$384.12 |
| Rate for Payer: AlohaCare Medicaid |
$198.00
|
| Rate for Payer: AlohaCare Medicare |
$198.00
|
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Cash Price |
$257.40
|
| Rate for Payer: Devoted Health Medicare |
$217.80
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$256.23
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$198.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$376.20
|
| Rate for Payer: Health Management Network Commercial |
$336.60
|
| Rate for Payer: Humana Medicare |
$198.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$356.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$201.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$198.00
|
| Rate for Payer: MDX Hawaii PPO |
$384.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$198.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$198.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$198.00
|
| Rate for Payer: University Health Alliance Commercial |
$221.76
|
|
|
Negative Pressure Wound Tx > 50cm
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
12740385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$692.75 |
| Max. Negotiated Rate |
$790.55 |
| Rate for Payer: Cash Price |
$529.75
|
| Rate for Payer: Health Management Network Commercial |
$692.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$733.50
|
| Rate for Payer: MDX Hawaii PPO |
$790.55
|
|
|
Negative Pressure Wound Tx > 50cm
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
HCPCS 97606
|
| Hospital Charge Code |
12740385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.32 |
| Max. Negotiated Rate |
$790.55 |
| Rate for Payer: AlohaCare Medicaid |
$407.50
|
| Rate for Payer: AlohaCare Medicare |
$407.50
|
| Rate for Payer: Cash Price |
$529.75
|
| Rate for Payer: Cash Price |
$529.75
|
| Rate for Payer: Devoted Health Medicare |
$448.25
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$519.15
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$407.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$774.25
|
| Rate for Payer: Health Management Network Commercial |
$692.75
|
| Rate for Payer: Humana Medicare |
$407.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$733.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$415.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$407.50
|
| Rate for Payer: MDX Hawaii PPO |
$790.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$407.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$407.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$20.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$407.50
|
| Rate for Payer: University Health Alliance Commercial |
$456.40
|
|
|
Neisseria gonorrheae RNA NAT Amp FSI
|
Facility
|
OP
|
$490.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
8118003
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$475.30 |
| Rate for Payer: AlohaCare Medicaid |
$245.00
|
| Rate for Payer: AlohaCare Medicare |
$245.00
|
| Rate for Payer: Cash Price |
$318.50
|
| Rate for Payer: Cash Price |
$318.50
|
| Rate for Payer: Devoted Health Medicare |
$269.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$416.50
|
| Rate for Payer: Humana Medicare |
$245.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$441.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$249.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.00
|
| Rate for Payer: MDX Hawaii PPO |
$475.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.00
|
| Rate for Payer: University Health Alliance Commercial |
$90.72
|
|
|
Neisseria gonorrheae RNA NAT Amp FSI
|
Facility
|
IP
|
$490.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
8118003
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$416.50 |
| Max. Negotiated Rate |
$475.30 |
| Rate for Payer: Cash Price |
$318.50
|
| Rate for Payer: Health Management Network Commercial |
$416.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$441.00
|
| Rate for Payer: MDX Hawaii PPO |
$475.30
|
|
|
Neisseria gonorrhoeae
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
12516221
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$141.95 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: Cash Price |
$108.55
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
|
|
Neisseria gonorrhoeae
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
12516221
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$161.99 |
| Rate for Payer: AlohaCare Medicaid |
$83.50
|
| Rate for Payer: AlohaCare Medicare |
$83.50
|
| Rate for Payer: Cash Price |
$108.55
|
| Rate for Payer: Cash Price |
$108.55
|
| Rate for Payer: Devoted Health Medicare |
$91.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$48.50
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$43.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$50.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$35.09
|
| Rate for Payer: Health Management Network Commercial |
$141.95
|
| Rate for Payer: Humana Medicare |
$83.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.50
|
| Rate for Payer: MDX Hawaii PPO |
$161.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.50
|
| Rate for Payer: University Health Alliance Commercial |
$90.72
|
|
|
neomyc-bacitrac-polymyx UD ointment [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 45802014370
|
| Hospital Charge Code |
2500098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
neomyc-bacitrac-polymyx UD ointment [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
2500098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
neomyc-bacitrac-polymyx UD ointment [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904880567
|
| Hospital Charge Code |
2500098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
neomyc-bacitrac-polymyx UD ointment [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 57896014314
|
| Hospital Charge Code |
2500098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
neomyc-bacitrac-polymyx UD ointment [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 57896014314
|
| Hospital Charge Code |
2500098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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
|
|
|
neomyc-bacitrac-polymyx UD ointment [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 45802014370
|
| Hospital Charge Code |
2500098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
neomy/polyb/HC 10ml otic drops [HHSC]
|
Facility
|
OP
|
$450.80
|
|
|
Service Code
|
NDC 24208063562
|
| Hospital Charge Code |
2500396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$225.40 |
| Max. Negotiated Rate |
$437.28 |
| Rate for Payer: AlohaCare Medicaid |
$225.40
|
| Rate for Payer: AlohaCare Medicare |
$225.40
|
| Rate for Payer: Cash Price |
$293.02
|
| Rate for Payer: Devoted Health Medicare |
$247.94
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$225.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$428.26
|
| Rate for Payer: Health Management Network Commercial |
$383.18
|
| Rate for Payer: Humana Medicare |
$225.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.72
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$225.40
|
| Rate for Payer: MDX Hawaii PPO |
$437.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$225.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$225.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$270.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$225.40
|
| Rate for Payer: University Health Alliance Commercial |
$328.59
|
|
|
neomy/polyb/HC 10ml otic drops [HHSC]
|
Facility
|
IP
|
$489.08
|
|
|
Service Code
|
NDC 64980044801
|
| Hospital Charge Code |
2500396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$415.72 |
| Max. Negotiated Rate |
$474.41 |
| Rate for Payer: Cash Price |
$317.90
|
| Rate for Payer: Health Management Network Commercial |
$415.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$440.17
|
| Rate for Payer: MDX Hawaii PPO |
$474.41
|
|
|
neomy/polyb/HC 10ml otic drops [HHSC]
|
Facility
|
OP
|
$489.08
|
|
|
Service Code
|
NDC 64980044801
|
| Hospital Charge Code |
2500396
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$244.54 |
| Max. Negotiated Rate |
$474.41 |
| Rate for Payer: AlohaCare Medicaid |
$244.54
|
| Rate for Payer: AlohaCare Medicare |
$244.54
|
| Rate for Payer: Cash Price |
$317.90
|
| Rate for Payer: Devoted Health Medicare |
$268.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$244.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$464.63
|
| Rate for Payer: Health Management Network Commercial |
$415.72
|
| Rate for Payer: Humana Medicare |
$244.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$440.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$249.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$244.54
|
| Rate for Payer: MDX Hawaii PPO |
$474.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$244.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$244.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$293.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$244.54
|
| Rate for Payer: University Health Alliance Commercial |
$356.49
|
|
