Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

vancomycin 125 mg Cap [KMC]

Facility

$12.24

Service Code	NDC 23155085878
Hospital Revenue Code	250
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$11.87
Rate for Payer: Cash Price	$7.96
Rate for Payer: Health Management Network Commercial	$10.40
Rate for Payer: Kaiser Permanente Commercial	$11.02
Rate for Payer: MDX Hawaii PPO	$11.87

vancomycin 1.5 gm / 300 mL premixed bag [KMC]

Facility

$0.72

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$8.20
Rate for Payer: AlohaCare Medicaid	$0.36
Rate for Payer: AlohaCare Medicare	$0.30
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cash Price	$0.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.66
Rate for Payer: Devoted Health Medicare	$0.30
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$0.30
Rate for Payer: Hawaii Western Management Group Commercial	$0.68
Rate for Payer: Health Management Network Commercial	$0.61
Rate for Payer: Humana Medicare	$0.30
Rate for Payer: Kaiser Permanente Commercial	$0.65
Rate for Payer: Kaiser Permanente Medicaid	$0.37
Rate for Payer: Kaiser Permanente Medicare	$0.30
Rate for Payer: MDX Hawaii PPO	$0.70
Rate for Payer: Ohana Health Plan Medicaid	$0.30
Rate for Payer: Ohana Health Plan Medicare	$0.30
Rate for Payer: UnitedHealthcare Medicaid	$0.43
Rate for Payer: UnitedHealthcare Medicare	$0.30
Rate for Payer: University Health Alliance Commercial	$0.52

vancomycin 1.5 gm / 300 mL premixed bag [KMC]

Facility

$0.72

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.70
Rate for Payer: Cash Price	$0.47
Rate for Payer: Health Management Network Commercial	$0.61
Rate for Payer: Kaiser Permanente Commercial	$0.65
Rate for Payer: MDX Hawaii PPO	$0.70

vancomycin 1.75 gm / 350 mL premixed bag [KMC]

Facility

$0.36

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Management Network Commercial	$0.31
Rate for Payer: Kaiser Permanente Commercial	$0.32
Rate for Payer: MDX Hawaii PPO	$0.35

vancomycin 1.75 gm / 350 mL premixed bag [KMC]

Facility

$0.36

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$8.20
Rate for Payer: AlohaCare Medicaid	$0.18
Rate for Payer: AlohaCare Medicare	$0.15
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.23
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.33
Rate for Payer: Devoted Health Medicare	$0.15
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$0.15
Rate for Payer: Hawaii Western Management Group Commercial	$0.34
Rate for Payer: Health Management Network Commercial	$0.31
Rate for Payer: Humana Medicare	$0.15
Rate for Payer: Kaiser Permanente Commercial	$0.32
Rate for Payer: Kaiser Permanente Medicaid	$0.18
Rate for Payer: Kaiser Permanente Medicare	$0.15
Rate for Payer: MDX Hawaii PPO	$0.35
Rate for Payer: Ohana Health Plan Medicaid	$0.15
Rate for Payer: Ohana Health Plan Medicare	$0.15
Rate for Payer: UnitedHealthcare Medicaid	$0.22
Rate for Payer: UnitedHealthcare Medicare	$0.15
Rate for Payer: University Health Alliance Commercial	$0.26

vancomycin 1 gm IV vial [KMC]

Facility

$24.12

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$23.40
Rate for Payer: Cash Price	$15.68
Rate for Payer: Health Management Network Commercial	$20.50
Rate for Payer: Kaiser Permanente Commercial	$21.71
Rate for Payer: MDX Hawaii PPO	$23.40

vancomycin 1 gm IV vial [KMC]

Facility

$24.12

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$23.40
Rate for Payer: AlohaCare Medicaid	$12.06
Rate for Payer: AlohaCare Medicare	$10.13
Rate for Payer: Cash Price	$15.68
Rate for Payer: Cash Price	$15.68
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$22.19
Rate for Payer: Devoted Health Medicare	$10.13
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$10.13
Rate for Payer: Hawaii Western Management Group Commercial	$22.91
Rate for Payer: Health Management Network Commercial	$20.50
Rate for Payer: Humana Medicare	$10.13
Rate for Payer: Kaiser Permanente Commercial	$21.71
Rate for Payer: Kaiser Permanente Medicaid	$12.30
Rate for Payer: Kaiser Permanente Medicare	$10.13
Rate for Payer: MDX Hawaii PPO	$23.40
Rate for Payer: Ohana Health Plan Medicaid	$10.13
Rate for Payer: Ohana Health Plan Medicare	$10.13
Rate for Payer: UnitedHealthcare Medicaid	$14.47
Rate for Payer: UnitedHealthcare Medicare	$10.13
Rate for Payer: University Health Alliance Commercial	$17.58

vancomycin 250 mg Cap

Facility

$230.86

Service Code	NDC 62559039150
Hospital Revenue Code	250
Min. Negotiated Rate	$196.23
Max. Negotiated Rate	$223.93
Rate for Payer: Cash Price	$150.06
Rate for Payer: Health Management Network Commercial	$196.23
Rate for Payer: Kaiser Permanente Commercial	$207.77
Rate for Payer: MDX Hawaii PPO	$223.93

vancomycin 250 mg Cap

Facility

$230.86

Service Code	NDC 62559039150
Hospital Revenue Code	250
Min. Negotiated Rate	$96.96
Max. Negotiated Rate	$223.93
Rate for Payer: AlohaCare Medicaid	$115.43
Rate for Payer: AlohaCare Medicare	$96.96
Rate for Payer: Cash Price	$150.06
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$212.39
Rate for Payer: Devoted Health Medicare	$96.96
Rate for Payer: Hawaii Medical Service Association Medicare	$96.96
Rate for Payer: Hawaii Western Management Group Commercial	$219.32
Rate for Payer: Health Management Network Commercial	$196.23
Rate for Payer: Humana Medicare	$96.96
Rate for Payer: Kaiser Permanente Commercial	$207.77
Rate for Payer: Kaiser Permanente Medicaid	$117.74
Rate for Payer: Kaiser Permanente Medicare	$96.96
Rate for Payer: MDX Hawaii PPO	$223.93
Rate for Payer: Ohana Health Plan Medicaid	$96.96
Rate for Payer: Ohana Health Plan Medicare	$96.96
Rate for Payer: UnitedHealthcare Medicaid	$138.52
Rate for Payer: UnitedHealthcare Medicare	$96.96
Rate for Payer: University Health Alliance Commercial	$168.27

vancomycin 500 mg IV Inj [KMC]

Facility

$14.40

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$13.97
Rate for Payer: AlohaCare Medicaid	$7.20
Rate for Payer: AlohaCare Medicare	$6.05
Rate for Payer: Cash Price	$9.36
Rate for Payer: Cash Price	$9.36
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$13.25
Rate for Payer: Devoted Health Medicare	$6.05
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$6.05
Rate for Payer: Hawaii Western Management Group Commercial	$13.68
Rate for Payer: Health Management Network Commercial	$12.24
Rate for Payer: Humana Medicare	$6.05
Rate for Payer: Kaiser Permanente Commercial	$12.96
Rate for Payer: Kaiser Permanente Medicaid	$7.34
Rate for Payer: Kaiser Permanente Medicare	$6.05
Rate for Payer: MDX Hawaii PPO	$13.97
Rate for Payer: Ohana Health Plan Medicaid	$6.05
Rate for Payer: Ohana Health Plan Medicare	$6.05
Rate for Payer: UnitedHealthcare Medicaid	$8.64
Rate for Payer: UnitedHealthcare Medicare	$6.05
Rate for Payer: University Health Alliance Commercial	$10.50

vancomycin 500 mg IV Inj [KMC]

Facility

$14.40

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$13.97
Rate for Payer: Cash Price	$9.36
Rate for Payer: Health Management Network Commercial	$12.24
Rate for Payer: Kaiser Permanente Commercial	$12.96
Rate for Payer: MDX Hawaii PPO	$13.97

vancomycin 750 mg/150 mL premixed bag [KMC]

Facility

$0.38

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Health Management Network Commercial	$0.32
Rate for Payer: Kaiser Permanente Commercial	$0.34
Rate for Payer: MDX Hawaii PPO	$0.37

vancomycin 750 mg/150 mL premixed bag [KMC]

Facility

$0.38

Service Code	HCPCS J3370
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$8.20
Rate for Payer: AlohaCare Medicaid	$0.19
Rate for Payer: AlohaCare Medicare	$0.16
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cash Price	$0.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.35
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$8.20
Rate for Payer: Hawaii Medical Service Association Medicare	$0.16
Rate for Payer: Hawaii Western Management Group Commercial	$0.36
Rate for Payer: Health Management Network Commercial	$0.32
Rate for Payer: Humana Medicare	$0.16
Rate for Payer: Kaiser Permanente Commercial	$0.34
Rate for Payer: Kaiser Permanente Medicaid	$0.19
Rate for Payer: Kaiser Permanente Medicare	$0.16
Rate for Payer: MDX Hawaii PPO	$0.37
Rate for Payer: Ohana Health Plan Medicaid	$0.16
Rate for Payer: Ohana Health Plan Medicare	$0.16
Rate for Payer: UnitedHealthcare Medicaid	$0.23
Rate for Payer: UnitedHealthcare Medicare	$0.16
Rate for Payer: University Health Alliance Commercial	$0.28

Vancomycin Lvl Peak 1

Facility

$200.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$184.00
Rate for Payer: Devoted Health Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin Lvl Peak 1

Facility

$200.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	301
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

Vancomycin Lvl Random

Facility

$200.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$184.00
Rate for Payer: Devoted Health Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin Lvl Random

Facility

$200.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	301
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

Vancomycin Lvl Trough 1

Facility

$200.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$194.00
Rate for Payer: AlohaCare Medicaid	$100.00
Rate for Payer: AlohaCare Medicare	$84.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$184.00
Rate for Payer: Devoted Health Medicare	$84.00
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Humana Medicare	$84.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: Kaiser Permanente Medicare	$84.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: Ohana Health Plan Medicaid	$84.00
Rate for Payer: Ohana Health Plan Medicare	$84.00
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$84.00
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin Lvl Trough 1

Facility

$200.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	301
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$180.00
Rate for Payer: MDX Hawaii PPO	$194.00

Vancomycin (No Time) DLS

Facility

$101.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	300
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$42.42
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.92
Rate for Payer: Devoted Health Medicare	$42.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$42.42
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$42.42
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$42.42
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$42.42
Rate for Payer: Ohana Health Plan Medicare	$42.42
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$42.42
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin (No Time) DLS

Facility

$101.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	300
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

Vancomycin (Peak) DLS

Facility

$101.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	300
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$42.42
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.92
Rate for Payer: Devoted Health Medicare	$42.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$42.42
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$42.42
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$42.42
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$42.42
Rate for Payer: Ohana Health Plan Medicare	$42.42
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$42.42
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin (Peak) DLS

Facility

$101.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	300
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

Vancomycin (Trough) DLS

Facility

$101.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	300
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$42.42
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$92.92
Rate for Payer: Devoted Health Medicare	$42.42
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.72
Rate for Payer: Hawaii Medical Service Association Commercial	$16.93
Rate for Payer: Hawaii Medical Service Association Medicare	$42.42
Rate for Payer: Hawaii Western Management Group Commercial	$13.54
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$42.42
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$42.42
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$42.42
Rate for Payer: Ohana Health Plan Medicare	$42.42
Rate for Payer: UnitedHealthcare Medicaid	$18.72
Rate for Payer: UnitedHealthcare Medicare	$42.42
Rate for Payer: University Health Alliance Commercial	$35.02

Vancomycin (Trough) DLS

Facility

$101.00

Service Code	HCPCS 80202
Hospital Charge Code	422802020
Hospital Revenue Code	300
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

Know your out-of-pocket cost for care.

All Charges