|
VIABAHN VBX EX BAL BXA097902A
|
Facility
|
OP
|
$7,688.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,844.00 |
| Max. Negotiated Rate |
$7,457.36 |
| Rate for Payer: AlohaCare Medicaid |
$3,844.00
|
| Rate for Payer: AlohaCare Medicare |
$5,842.88
|
| Rate for Payer: Cash Price |
$4,612.80
|
| Rate for Payer: Devoted Health Medicare |
$6,457.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,842.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,381.60
|
| Rate for Payer: Health Management Network Commercial |
$6,534.80
|
| Rate for Payer: Humana Medicare |
$5,842.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,919.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,920.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,842.88
|
| Rate for Payer: MDX Hawaii PPO |
$7,457.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,842.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,842.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,842.88
|
| Rate for Payer: University Health Alliance Commercial |
$4,305.28
|
|
|
VIABAHN VBX EX BAL BXA115901A
|
Facility
|
OP
|
$7,148.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,574.00 |
| Max. Negotiated Rate |
$6,933.56 |
| Rate for Payer: AlohaCare Medicaid |
$3,574.00
|
| Rate for Payer: AlohaCare Medicare |
$5,432.48
|
| Rate for Payer: Cash Price |
$4,288.80
|
| Rate for Payer: Devoted Health Medicare |
$6,004.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,432.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,003.60
|
| Rate for Payer: Health Management Network Commercial |
$6,075.80
|
| Rate for Payer: Humana Medicare |
$5,432.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,433.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,645.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,432.48
|
| Rate for Payer: MDX Hawaii PPO |
$6,933.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,432.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,432.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,432.48
|
| Rate for Payer: University Health Alliance Commercial |
$4,002.88
|
|
|
VIABAHN VBX EX BAL BXA115901A
|
Facility
|
IP
|
$7,148.00
|
|
|
Service Code
|
HCPCS C1874
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,002.88 |
| Max. Negotiated Rate |
$6,933.56 |
| Rate for Payer: Cash Price |
$4,288.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,003.60
|
| Rate for Payer: Health Management Network Commercial |
$6,075.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,433.20
|
| Rate for Payer: MDX Hawaii PPO |
$6,933.56
|
| Rate for Payer: University Health Alliance Commercial |
$4,002.88
|
|
|
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS J9360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.90 |
| Max. Negotiated Rate |
$188.18 |
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$164.90
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: MDX Hawaii PPO |
$188.18
|
|
|
VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS J9360
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.29 |
| Max. Negotiated Rate |
$188.18 |
| Rate for Payer: AlohaCare Medicaid |
$97.00
|
| Rate for Payer: AlohaCare Medicaid |
$29.00
|
| Rate for Payer: AlohaCare Medicare |
$44.08
|
| Rate for Payer: AlohaCare Medicare |
$147.44
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Devoted Health Medicare |
$162.96
|
| Rate for Payer: Devoted Health Medicare |
$48.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$184.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.10
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Health Management Network Commercial |
$164.90
|
| Rate for Payer: Humana Medicare |
$147.44
|
| Rate for Payer: Humana Medicare |
$44.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.08
|
| Rate for Payer: MDX Hawaii PPO |
$188.18
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$147.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$116.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.08
|
| Rate for Payer: University Health Alliance Commercial |
$141.41
|
| Rate for Payer: University Health Alliance Commercial |
$42.28
|
|
|
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS J9370
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$52.38 |
| Rate for Payer: AlohaCare Medicaid |
$27.00
|
| Rate for Payer: AlohaCare Medicare |
$41.04
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Devoted Health Medicare |
$45.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$41.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$51.30
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: Humana Medicare |
$41.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.04
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$41.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$32.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$41.04
|
| Rate for Payer: University Health Alliance Commercial |
$39.36
|
|
|
VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS J9370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.90 |
| Max. Negotiated Rate |
$52.38 |
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Health Management Network Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$48.60
|
| Rate for Payer: MDX Hawaii PPO |
$52.38
|
|
|
VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [199441]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J9370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [199441]
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
HCPCS J9370
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.86 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$39.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS J9390
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$136.00 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
|
|
VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION [41673]
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS J9390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$155.20 |
| Rate for Payer: AlohaCare Medicaid |
$80.00
|
| Rate for Payer: AlohaCare Medicaid |
$135.00
|
| Rate for Payer: AlohaCare Medicare |
$205.20
|
| Rate for Payer: AlohaCare Medicare |
$121.60
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Devoted Health Medicare |
$134.40
|
| Rate for Payer: Devoted Health Medicare |
$226.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$205.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$121.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$152.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$256.50
|
| Rate for Payer: Health Management Network Commercial |
$229.50
|
| Rate for Payer: Health Management Network Commercial |
$136.00
|
| Rate for Payer: Humana Medicare |
$121.60
|
| Rate for Payer: Humana Medicare |
$205.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$144.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$243.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$137.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$81.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$121.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$205.20
|
| Rate for Payer: MDX Hawaii PPO |
$155.20
|
| Rate for Payer: MDX Hawaii PPO |
$261.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$205.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$121.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$121.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$205.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$162.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$96.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$121.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$205.20
|
| Rate for Payer: University Health Alliance Commercial |
$116.62
|
| Rate for Payer: University Health Alliance Commercial |
$196.80
|
|
|
VIRAL ILLNESS WITH MCC
|
Facility
|
IP
|
$24,341.95
|
|
|
Service Code
|
MSDRG 865
|
| Min. Negotiated Rate |
$24,341.95 |
| Max. Negotiated Rate |
$24,341.95 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$24,341.95
|
|
|
VIRAL ILLNESS WITHOUT MCC
|
Facility
|
IP
|
$22,825.03
|
|
|
Service Code
|
MSDRG 866
|
| Min. Negotiated Rate |
$22,825.03 |
| Max. Negotiated Rate |
$22,825.03 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22,825.03
|
|
|
VIRAL MENINGITIS WITH CC/MCC
|
Facility
|
IP
|
$14,102.69
|
|
|
Service Code
|
MSDRG 075
|
| Min. Negotiated Rate |
$14,102.69 |
| Max. Negotiated Rate |
$14,102.69 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,102.69
|
|
|
VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$14,102.69
|
|
|
Service Code
|
MSDRG 076
|
| Min. Negotiated Rate |
$14,102.69 |
| Max. Negotiated Rate |
$14,102.69 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14,102.69
|
|
|
VISIONIST X4
|
Facility
|
OP
|
$11,512.00
|
|
|
Service Code
|
HCPCS C2621
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$5,756.00 |
| Max. Negotiated Rate |
$11,166.64 |
| Rate for Payer: AlohaCare Medicaid |
$5,756.00
|
| Rate for Payer: AlohaCare Medicare |
$8,749.12
|
| Rate for Payer: Cash Price |
$6,907.20
|
| Rate for Payer: Devoted Health Medicare |
$9,670.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,749.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,058.40
|
| Rate for Payer: Health Management Network Commercial |
$9,785.20
|
| Rate for Payer: Humana Medicare |
$8,749.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,360.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,871.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,749.12
|
| Rate for Payer: MDX Hawaii PPO |
$11,166.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,749.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,749.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,749.12
|
| Rate for Payer: University Health Alliance Commercial |
$6,446.72
|
|
|
VISIONIST X4
|
Facility
|
IP
|
$11,512.00
|
|
|
Service Code
|
HCPCS C2621
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$6,446.72 |
| Max. Negotiated Rate |
$11,166.64 |
| Rate for Payer: Cash Price |
$6,907.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8,058.40
|
| Rate for Payer: Health Management Network Commercial |
$9,785.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,360.80
|
| Rate for Payer: MDX Hawaii PPO |
$11,166.64
|
| Rate for Payer: University Health Alliance Commercial |
$6,446.72
|
|
|
VISTA COLLAR, ADULT 79-83370
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
HCPCS L0172
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$112.56 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$140.70
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
| Rate for Payer: University Health Alliance Commercial |
$112.56
|
|
|
VISTA COLLAR, ADULT 79-83370
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
HCPCS L0172
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$78.38 |
| Max. Negotiated Rate |
$194.97 |
| Rate for Payer: AlohaCare Medicaid |
$100.50
|
| Rate for Payer: AlohaCare Medicare |
$152.76
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Cash Price |
$120.60
|
| Rate for Payer: Devoted Health Medicare |
$168.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$140.70
|
| Rate for Payer: Health Management Network Commercial |
$170.85
|
| Rate for Payer: Humana Medicare |
$152.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$180.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$102.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.76
|
| Rate for Payer: MDX Hawaii PPO |
$194.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$152.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$152.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$78.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.76
|
| Rate for Payer: University Health Alliance Commercial |
$112.56
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [201407]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 40725000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
VITAMIN A PALMITATE 3,000 MCG (10,000 UNIT) CAPSULE [201407]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 40725000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
VITAMIN B COMPLEX CAPSULE [804]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 37801000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
VITAMIN B COMPLEX CAPSULE [804]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 37801000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET [5495]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 16001000000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET [5495]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 16001000000
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: AlohaCare Medicaid |
$0.50
|
| Rate for Payer: AlohaCare Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Devoted Health Medicare |
$0.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Humana Medicare |
$0.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.76
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.76
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
