|
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 |
$1.55
|
| Rate for Payer: AlohaCare Medicare |
$1.86
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: AlohaCare Medicare |
$15.19
|
| 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 |
$1.70
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Devoted Health Medicare |
$2.04
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Devoted Health Medicare |
$16.66
|
| 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 |
$1.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| 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 |
$1.55
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Humana Medicare |
$15.19
|
| Rate for Payer: Humana Medicare |
$1.86
|
| Rate for Payer: Humana Medicare |
$2.17
|
| 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 |
$15.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| 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 |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| 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 |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| 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
|
$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 10 GRAM INTRAVENOUS SOLUTION [11627]
|
Facility
|
OP
|
$132.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.92 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$40.92
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Devoted Health Medicare |
$44.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$40.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.92
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$79.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.92
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
|
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 |
$119.66
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Cash Price |
$231.60
|
| Rate for Payer: Devoted Health Medicare |
$131.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$119.66
|
| 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 |
$119.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$347.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$196.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$119.66
|
| Rate for Payer: MDX Hawaii PPO |
$374.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$119.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$119.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$231.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$119.66
|
| Rate for Payer: University Health Alliance Commercial |
$281.36
|
|
|
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 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 |
$26.04
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Devoted Health Medicare |
$28.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$26.04
|
| 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 |
$26.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.04
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.04
|
| 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 |
$30.07
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Devoted Health Medicare |
$32.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$30.07
|
| 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 |
$30.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$30.07
|
| Rate for Payer: MDX Hawaii PPO |
$94.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$30.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$30.07
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$30.07
|
| 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
|
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 |
$22.63
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$24.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.31
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.63
|
| 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 |
$22.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.63
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.63
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.63
|
| 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: AlohaCare Medicaid |
$37.00
|
| Rate for Payer: AlohaCare Medicare |
$22.94
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Devoted Health Medicare |
$25.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.94
|
| 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 |
$22.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.94
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.94
|
| Rate for Payer: University Health Alliance Commercial |
$53.94
|
|
|
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 1.75 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 1.75 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 |
$34.10
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Cash Price |
$66.00
|
| Rate for Payer: Devoted Health Medicare |
$37.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$34.10
|
| 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 |
$34.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.10
|
| Rate for Payer: MDX Hawaii PPO |
$106.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.10
|
| Rate for Payer: University Health Alliance Commercial |
$80.18
|
|
|
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 |
$21.08
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Devoted Health Medicare |
$23.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.08
|
| 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 |
$21.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$61.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.08
|
| Rate for Payer: MDX Hawaii PPO |
$65.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$40.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.08
|
| Rate for Payer: University Health Alliance Commercial |
$49.57
|
|
|
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 |
$36.58
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Devoted Health Medicare |
$40.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.58
|
| 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 |
$36.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$106.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.58
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.58
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
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 |
$11.78
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Devoted Health Medicare |
$12.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.78
|
| 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 |
$11.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$34.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.78
|
| Rate for Payer: MDX Hawaii PPO |
$36.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$22.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.78
|
| Rate for Payer: University Health Alliance Commercial |
$27.70
|
|
|
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 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 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 |
$9.30
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Devoted Health Medicare |
$10.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.30
|
| 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 |
$9.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.30
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.30
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
|
|
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 |
$15.81
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Devoted Health Medicare |
$17.34
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.81
|
| 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 |
$15.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.81
|
| Rate for Payer: MDX Hawaii PPO |
$49.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$30.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.81
|
| Rate for Payer: University Health Alliance Commercial |
$37.17
|
|
