|
VALSARTAN 160 MG TABLET [31210]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687063411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
VALSARTAN 160 MG TABLET [31210]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 60687063401
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
VALSARTAN 40 MG TABLET [33541]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 31722015130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
VALSARTAN 40 MG TABLET [33541]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 55111073130
|
|
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
|
|
|
VALSARTAN 40 MG TABLET [33541]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 31722015130
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
VALSARTAN 40 MG TABLET [33541]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 55111073130
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
VALVE QUICK FLUSH #AR-2700
|
Facility
|
OP
|
$129.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.50 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicare |
$98.04
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Devoted Health Medicare |
$108.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.55
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Humana Medicare |
$98.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.04
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.04
|
| Rate for Payer: University Health Alliance Commercial |
$94.03
|
|
|
VALVE QUICK FLUSH #AR-2700
|
Facility
|
IP
|
$129.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$109.65 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Health Management Network Commercial |
$109.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
|
|
VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [162638]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [162638]
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: AlohaCare Medicare |
$5.32
|
| Rate for Payer: AlohaCare Medicare |
$7.60
|
| Rate for Payer: AlohaCare Medicare |
$37.24
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| Rate for Payer: Devoted Health Medicare |
$5.88
|
| Rate for Payer: Devoted Health Medicare |
$41.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Humana Medicare |
$7.60
|
| Rate for Payer: Humana Medicare |
$37.24
|
| Rate for Payer: Humana Medicare |
$4.56
|
| Rate for Payer: Humana Medicare |
$5.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.32
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]
|
Facility
|
IP
|
$132.00
|
|
|
Service Code
|
HCPCS J3490
|
|
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
|
|
|
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]
|
Facility
|
OP
|
$386.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$374.42 |
| Rate for Payer: AlohaCare Medicaid |
$193.00
|
| Rate for Payer: AlohaCare Medicare |
$293.36
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Devoted Health Medicare |
$324.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$293.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$366.70
|
| Rate for Payer: Health Management Network Commercial |
$328.10
|
| Rate for Payer: Humana Medicare |
$293.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$196.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$293.36
|
| Rate for Payer: MDX Hawaii PPO |
$374.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$293.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$293.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$231.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$293.36
|
| Rate for Payer: University Health Alliance Commercial |
$281.36
|
|
|
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$100.32
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Devoted Health Medicare |
$110.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$100.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$100.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.32
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$100.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$100.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$79.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$100.32
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
|
VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]
|
Facility
|
IP
|
$386.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$328.10 |
| Max. Negotiated Rate |
$374.42 |
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Health Management Network Commercial |
$328.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.40
|
| Rate for Payer: MDX Hawaii PPO |
$374.42
|
|
|
VANCOMYCIN 1.25 GRAM/250 ML IN DILUENT COMBINATION IV PIGGYBACK [174638]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Devoted Health Medicare |
$70.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
VANCOMYCIN 1.25 GRAM/250 ML IN DILUENT COMBINATION IV PIGGYBACK [174638]
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
|
|
VANCOMYCIN 1.5 GRAM/300 ML IN DILUENT COMBINATION IV PIGGYBACK [166612]
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: AlohaCare Medicaid |
$48.50
|
| Rate for Payer: AlohaCare Medicare |
$73.72
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Devoted Health Medicare |
$81.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$73.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$92.15
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Humana Medicare |
$73.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$73.72
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$73.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$73.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$73.72
|
| Rate for Payer: University Health Alliance Commercial |
$70.70
|
|
|
VANCOMYCIN 1.5 GRAM/300 ML IN DILUENT COMBINATION IV PIGGYBACK [166612]
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.45 |
| Max. Negotiated Rate |
$94.09 |
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Health Management Network Commercial |
$82.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
|
|
VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS J3371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
|
VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS J3371
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.31 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.35
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: University Health Alliance Commercial |
$53.21
|
|
|
VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION [164996]
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Ohana Health Plan Medicaid |
$56.24
|
| Rate for Payer: AlohaCare Medicaid |
$37.00
|
| Rate for Payer: AlohaCare Medicare |
$56.24
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Devoted Health Medicare |
$62.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.30
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Humana Medicare |
$56.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.24
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.24
|
| Rate for Payer: University Health Alliance Commercial |
$53.94
|
|
|
VANCOMYCIN 1.75 GRAM/350 ML IN DILUENT COMBINATION IV PIGGYBACK [174639]
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: AlohaCare Medicaid |
$55.00
|
| Rate for Payer: AlohaCare Medicare |
$83.60
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Devoted Health Medicare |
$92.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$104.50
|
| Rate for Payer: Health Management Network Commercial |
$93.50
|
| Rate for Payer: Humana Medicare |
$83.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.60
|
| Rate for Payer: MDX Hawaii PPO |
$106.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.60
|
| Rate for Payer: University Health Alliance Commercial |
$80.18
|
|
|
VANCOMYCIN 1.75 GRAM/350 ML IN DILUENT COMBINATION IV PIGGYBACK [174639]
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.50 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Health Management Network Commercial |
$93.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.00
|
| Rate for Payer: MDX Hawaii PPO |
$106.70
|
|
|
VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK [166611]
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$65.96 |
| Rate for Payer: AlohaCare Medicaid |
$34.00
|
| Rate for Payer: AlohaCare Medicare |
$51.68
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Devoted Health Medicare |
$57.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$51.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$64.60
|
| Rate for Payer: Health Management Network Commercial |
$57.80
|
| Rate for Payer: Humana Medicare |
$51.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.68
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$51.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$51.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$51.68
|
| Rate for Payer: University Health Alliance Commercial |
$49.57
|
|
