|
VITOSS BONE GRAFT 2102-2205
|
Facility
|
OP
|
$7,048.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,594.48 |
| Max. Negotiated Rate |
$6,836.56 |
| Rate for Payer: Cash Price |
$4,228.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,933.60
|
| Rate for Payer: Health Management Network Commercial |
$5,990.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,440.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,594.48
|
| Rate for Payer: MDX Hawaii PPO |
$6,836.56
|
| Rate for Payer: University Health Alliance Commercial |
$3,946.88
|
|
|
VIVACIT-E 60X36MM 8851-014-36
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,938.00 |
| Max. Negotiated Rate |
$3,686.00 |
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,660.00
|
| Rate for Payer: Health Management Network Commercial |
$3,230.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,394.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,938.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,686.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,128.00
|
|
|
VIVACIT-E 60X36MM 8851-014-36
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,128.00 |
| Max. Negotiated Rate |
$3,686.00 |
| Rate for Payer: Cash Price |
$2,280.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,660.00
|
| Rate for Payer: Health Management Network Commercial |
$3,230.00
|
| Rate for Payer: MDX Hawaii PPO |
$3,686.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,128.00
|
|
|
VLOC 3-0 CV-23 6" VLOCM0804
|
Facility
|
IP
|
$124.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.40 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Health Management Network Commercial |
$105.40
|
| Rate for Payer: MDX Hawaii PPO |
$120.28
|
|
|
VLOC 3-0 CV-23 6" VLOCM0804
|
Facility
|
OP
|
$124.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.24 |
| Max. Negotiated Rate |
$120.28 |
| Rate for Payer: Cash Price |
$74.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$117.80
|
| Rate for Payer: Health Management Network Commercial |
$105.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.24
|
| Rate for Payer: MDX Hawaii PPO |
$120.28
|
| Rate for Payer: University Health Alliance Commercial |
$90.38
|
|
|
VOL PLATE RT/5H/5PEG VLBPR-5-5
|
Facility
|
OP
|
$3,020.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,540.20 |
| Max. Negotiated Rate |
$2,929.40 |
| Rate for Payer: Cash Price |
$1,812.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,114.00
|
| Rate for Payer: Health Management Network Commercial |
$2,567.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,902.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,540.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,929.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,691.20
|
|
|
VOL PLATE RT/5H/5PEG VLBPR-5-5
|
Facility
|
IP
|
$3,020.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,691.20 |
| Max. Negotiated Rate |
$2,929.40 |
| Rate for Payer: Cash Price |
$1,812.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,114.00
|
| Rate for Payer: Health Management Network Commercial |
$2,567.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,929.40
|
| Rate for Payer: University Health Alliance Commercial |
$1,691.20
|
|
|
VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL) [43033010]
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS J3465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$106.25 |
| Max. Negotiated Rate |
$121.25 |
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
|
|
VORICONAZOLE 200 MG/20ML IV (WET SOLR VIAL) [43033010]
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS J3465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.78
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$118.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.75
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Health Management Network Commercial |
$106.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$63.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.95
|
| Rate for Payer: MDX Hawaii PPO |
$121.25
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.00
|
| Rate for Payer: University Health Alliance Commercial |
$105.69
|
| Rate for Payer: University Health Alliance Commercial |
$91.11
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]
|
Facility
|
IP
|
$145.00
|
|
|
Service Code
|
HCPCS J3465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$123.25 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
|
|
VORICONAZOLE 200 MG INTRAVENOUS SOLUTION [33010]
|
Facility
|
OP
|
$145.00
|
|
|
Service Code
|
HCPCS J3465
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.75
|
| Rate for Payer: Health Management Network Commercial |
$123.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$91.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$73.95
|
| Rate for Payer: MDX Hawaii PPO |
$140.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.00
|
| Rate for Payer: University Health Alliance Commercial |
$105.69
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
NDC 68462057330
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50268080311
|
|
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: MDX Hawaii PPO |
$58.20
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50268080311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
NDC 00904702404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.17 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.65
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.17
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
| Rate for Payer: University Health Alliance Commercial |
$48.84
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
NDC 68462057330
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$152.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.60
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
| Rate for Payer: University Health Alliance Commercial |
$116.62
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
NDC 60687027321
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.18 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.10
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
NDC 60687027311
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.18 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.10
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
NDC 50268080312
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.60 |
| Max. Negotiated Rate |
$58.20 |
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$57.00
|
| Rate for Payer: Health Management Network Commercial |
$51.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$30.60
|
| Rate for Payer: MDX Hawaii PPO |
$58.20
|
| Rate for Payer: University Health Alliance Commercial |
$43.73
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
NDC 60687027321
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
NDC 60687027311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
NDC 50268080312
|
|
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: MDX Hawaii PPO |
$58.20
|
|
|
VORICONAZOLE 200 MG TABLET [33009]
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 00904702404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
VSI MICRO-INTRO 4F ECHO STIFFE
|
Facility
|
OP
|
$114.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.14 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$108.30
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.14
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
| Rate for Payer: University Health Alliance Commercial |
$83.09
|
|
|
VSI MICRO-INTRO 4F ECHO STIFFE
|
Facility
|
IP
|
$114.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
|
