|
VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK [166611]
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
VANCOMYCIN 25 MG/ML ORAL SOLUTION [160236]
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
NDC 65628020405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$480.25 |
| Max. Negotiated Rate |
$548.05 |
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Health Management Network Commercial |
$480.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$508.50
|
| Rate for Payer: MDX Hawaii PPO |
$548.05
|
|
|
VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK [168896]
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3375
|
|
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: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK [168896]
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: AlohaCare Medicaid |
$59.00
|
| Rate for Payer: AlohaCare Medicare |
$89.68
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Devoted Health Medicare |
$99.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.10
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Humana Medicare |
$89.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.68
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.68
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
VANCOMYCIN 500 MG/100 ML IN DILUENT COMBINATION IV PIGGYBACK [170119]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS J3375
|
|
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
|
|
|
VANCOMYCIN 500 MG/100 ML IN DILUENT COMBINATION IV PIGGYBACK [170119]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$36.86 |
| Rate for Payer: AlohaCare Medicaid |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$28.88
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Devoted Health Medicare |
$31.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.10
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Humana Medicare |
$28.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.88
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.88
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
VANCOMYCIN 500 MG INTRAVENOUS SOLUTION [8443]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
VANCOMYCIN 750 MG/150 ML IN DILUENT COMBINATION IV PIGGYBACK [174637]
|
Facility
|
IP
|
$51.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.35 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
|
|
VANCOMYCIN 750 MG/150 ML IN DILUENT COMBINATION IV PIGGYBACK [174637]
|
Facility
|
OP
|
$51.00
|
|
|
Service Code
|
HCPCS J3375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$49.47 |
| Rate for Payer: AlohaCare Medicaid |
$25.50
|
| Rate for Payer: AlohaCare Medicare |
$38.76
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$38.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$48.45
|
| Rate for Payer: Health Management Network Commercial |
$43.35
|
| Rate for Payer: Humana Medicare |
$38.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$38.76
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$38.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$38.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$38.76
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
|
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
VANCOMYCIN 750 MG INTRAVENOUS SOLUTION [97371]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicaid |
$14.50
|
| Rate for Payer: AlohaCare Medicare |
$22.04
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$24.36
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| 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 |
$22.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| 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 |
$27.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$22.04
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.04
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
VANCOMYCIN HCL 10 G/100ML IV (WET SOLR VIAL) [43011627]
|
Facility
|
OP
|
$386.00
|
|
|
Service Code
|
HCPCS J3376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$193.00 |
| 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: Devoted Health Medicare |
$324.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$293.36
|
| 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 HCL 10 G/100ML IV (WET SOLR VIAL) [43011627]
|
Facility
|
IP
|
$386.00
|
|
|
Service Code
|
HCPCS J3376
|
|
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 HCL 1.5 G/30ML IV (WET SOLR VIAL) [430164996]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS J3370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
|
VANCOMYCIN HCL 1.5 G/30ML IV (WET SOLR VIAL) [430164996]
|
Facility
|
OP
|
$74.00
|
|
|
Service Code
|
HCPCS J3370
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: AlohaCare Medicaid |
$37.00
|
| Rate for Payer: AlohaCare Medicaid |
$43.00
|
| Rate for Payer: AlohaCare Medicare |
$65.36
|
| Rate for Payer: AlohaCare Medicare |
$56.24
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Devoted Health Medicare |
$62.16
|
| Rate for Payer: Devoted Health Medicare |
$72.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$56.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$70.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$81.70
|
| Rate for Payer: Health Management Network Commercial |
$73.10
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: Humana Medicare |
$65.36
|
| Rate for Payer: Humana Medicare |
$56.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$77.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$43.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.36
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
| Rate for Payer: MDX Hawaii PPO |
$83.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$56.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$51.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$56.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.36
|
| Rate for Payer: University Health Alliance Commercial |
$53.94
|
| Rate for Payer: University Health Alliance Commercial |
$62.69
|
|
|
VANCOMYCIN HCL 1 G/20ML IV (WET SOLR VIAL) [430162638]
|
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: Humana Medicare |
$4.56
|
| Rate for Payer: AlohaCare Medicaid |
$2.50
|
| Rate for Payer: AlohaCare Medicaid |
$3.00
|
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: AlohaCare Medicare |
$37.24
|
| Rate for Payer: AlohaCare Medicare |
$3.80
|
| Rate for Payer: AlohaCare Medicare |
$4.56
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Devoted Health Medicare |
$41.16
|
| Rate for Payer: Devoted Health Medicare |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Devoted Health Medicare |
$5.04
|
| 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 |
$37.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.80
|
| 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 |
$2.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Humana Medicare |
$37.24
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Humana Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.55
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
| Rate for Payer: University Health Alliance Commercial |
$3.64
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
| Rate for Payer: University Health Alliance Commercial |
$35.72
|
|
|
VANCOMYCIN HCL 1 G/20ML IV (WET SOLR VIAL) [430162638]
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL) [4308443]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicare |
$22.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$25.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.80
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$22.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.80
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.80
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
VANCOMYCIN HCL 500 MG/10ML IV (WET SOLR VIAL) [4308443]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
|
VANCOMYCIN HCL 750 MG/15ML IV (WET SOLR VIAL) [43097371]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
VANCOMYCIN HCL 750 MG/15ML IV (WET SOLR VIAL) [43097371]
|
Facility
|
OP
|
$29.00
|
|
|
Service Code
|
HCPCS J3373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: AlohaCare Medicaid |
$14.50
|
| Rate for Payer: AlohaCare Medicare |
$22.04
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Devoted Health Medicare |
$24.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.55
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Humana Medicare |
$22.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.04
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.04
|
| Rate for Payer: University Health Alliance Commercial |
$21.14
|
|
|
VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [113088]
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
NDC 00006482700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$294.10 |
| Max. Negotiated Rate |
$335.62 |
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Health Management Network Commercial |
$294.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.40
|
| Rate for Payer: MDX Hawaii PPO |
$335.62
|
|
|
VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP [113088]
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
NDC 00006482701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$294.10 |
| Max. Negotiated Rate |
$335.62 |
| Rate for Payer: Cash Price |
$207.60
|
| Rate for Payer: Health Management Network Commercial |
$294.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$311.40
|
| Rate for Payer: MDX Hawaii PPO |
$335.62
|
|
|
VAS DILATR 12X20 G03929
|
Facility
|
OP
|
$104.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.00 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: AlohaCare Medicaid |
$52.00
|
| Rate for Payer: AlohaCare Medicare |
$79.04
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Devoted Health Medicare |
$87.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$79.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.80
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Humana Medicare |
$79.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$79.04
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$79.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$79.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$79.04
|
| Rate for Payer: University Health Alliance Commercial |
$75.81
|
|
