|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 75 MM
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13017690
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.00 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$155.00
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Devoted Health Medicare |
$170.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$155.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.00
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 7 MM
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13017689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 7 MM
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13017689
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.00 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$155.00
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Devoted Health Medicare |
$170.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$155.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.00
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 80 MM
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13008360
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.00 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$155.00
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Devoted Health Medicare |
$170.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$155.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.00
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 80 MM
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13008360
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 8 MM
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13017688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 8 MM
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13017688
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.00 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$155.00
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Devoted Health Medicare |
$170.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$155.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.00
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 9 MM
|
Facility
|
OP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$155.00 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: AlohaCare Medicaid |
$155.00
|
| Rate for Payer: AlohaCare Medicare |
$155.00
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Devoted Health Medicare |
$170.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$155.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Humana Medicare |
$155.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$158.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$155.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$155.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$155.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$155.00
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VAL VAL KREULOCK SCREW, TI, 2.7 MM X 9 MM
|
Facility
|
IP
|
$310.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
13006717
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$173.60 |
| Max. Negotiated Rate |
$300.70 |
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$217.00
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$279.00
|
| Rate for Payer: MDX Hawaii PPO |
$300.70
|
| Rate for Payer: University Health Alliance Commercial |
$173.60
|
|
|
VALVE HEIMLICH CHEST DRAIN
|
Facility
|
OP
|
$505.00
|
|
| Hospital Charge Code |
8266711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.50 |
| Max. Negotiated Rate |
$489.85 |
| Rate for Payer: AlohaCare Medicaid |
$252.50
|
| Rate for Payer: AlohaCare Medicare |
$252.50
|
| Rate for Payer: Cash Price |
$328.25
|
| Rate for Payer: Devoted Health Medicare |
$277.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$252.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$479.75
|
| Rate for Payer: Health Management Network Commercial |
$429.25
|
| Rate for Payer: Humana Medicare |
$252.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$454.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$257.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$252.50
|
| Rate for Payer: MDX Hawaii PPO |
$489.85
|
| Rate for Payer: Ohana Health Plan Medicaid |
$252.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$252.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$252.50
|
| Rate for Payer: University Health Alliance Commercial |
$368.09
|
|
|
VALVE HEIMLICH CHEST DRAIN
|
Facility
|
IP
|
$505.00
|
|
| Hospital Charge Code |
8266711
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$429.25 |
| Max. Negotiated Rate |
$489.85 |
| Rate for Payer: Cash Price |
$328.25
|
| Rate for Payer: Health Management Network Commercial |
$429.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$454.50
|
| Rate for Payer: MDX Hawaii PPO |
$489.85
|
|
|
vancomycin 1000mg/200mL-SWFI premix [HHSC]
|
Facility
|
OP
|
$168.63
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
2501001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$163.57 |
| Rate for Payer: AlohaCare Medicaid |
$84.31
|
| Rate for Payer: AlohaCare Medicare |
$84.31
|
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Devoted Health Medicare |
$92.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.31
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$160.20
|
| Rate for Payer: Health Management Network Commercial |
$143.34
|
| Rate for Payer: Humana Medicare |
$84.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.31
|
| Rate for Payer: MDX Hawaii PPO |
$163.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.31
|
| Rate for Payer: University Health Alliance Commercial |
$122.91
|
|
|
vancomycin 1000mg/200mL-SWFI premix [HHSC]
|
Facility
|
IP
|
$168.63
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
2501001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.34 |
| Max. Negotiated Rate |
$163.57 |
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Health Management Network Commercial |
$143.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.77
|
| Rate for Payer: MDX Hawaii PPO |
$163.57
|
|
|
vancomycin 1000mg vial [HHSC]
|
Facility
|
IP
|
$97.90
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
2500846
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.22 |
| Max. Negotiated Rate |
$94.96 |
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$64.88
|
| Rate for Payer: Cash Price |
$64.10
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Health Management Network Commercial |
$15.31
|
| Rate for Payer: Health Management Network Commercial |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$83.22
|
| Rate for Payer: Health Management Network Commercial |
$83.82
|
| Rate for Payer: Health Management Network Commercial |
$84.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$96.82
|
| Rate for Payer: MDX Hawaii PPO |
$95.65
|
| Rate for Payer: MDX Hawaii PPO |
$94.96
|
| Rate for Payer: MDX Hawaii PPO |
$17.47
|
| Rate for Payer: MDX Hawaii PPO |
$42.46
|
|
|
vancomycin 1000mg vial [HHSC]
|
Facility
|
OP
|
$18.01
|
|
|
Service Code
|
HCPCS J3373
|
| Hospital Charge Code |
2500846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$17.47 |
| Rate for Payer: AlohaCare Medicaid |
$9.01
|
| Rate for Payer: AlohaCare Medicaid |
$21.89
|
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicaid |
$48.95
|
| Rate for Payer: AlohaCare Medicaid |
$49.91
|
| Rate for Payer: AlohaCare Medicaid |
$49.30
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$49.91
|
| Rate for Payer: AlohaCare Medicare |
$21.89
|
| Rate for Payer: AlohaCare Medicare |
$49.30
|
| Rate for Payer: AlohaCare Medicare |
$9.01
|
| Rate for Payer: AlohaCare Medicare |
$48.95
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$11.71
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cash Price |
$28.45
|
| Rate for Payer: Cash Price |
$64.88
|
| Rate for Payer: Cash Price |
$64.88
|
| Rate for Payer: Cash Price |
$64.10
|
| Rate for Payer: Cash Price |
$64.10
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Cash Price |
$63.64
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Devoted Health Medicare |
$24.07
|
| Rate for Payer: Devoted Health Medicare |
$54.90
|
| Rate for Payer: Devoted Health Medicare |
$53.84
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$9.91
|
| Rate for Payer: Devoted Health Medicare |
$54.24
|
| 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 ABD |
$0.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.89
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$49.91
|
| 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 Medical Service Association Non-ABD |
$0.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.11
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$93.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$94.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.58
|
| Rate for Payer: Health Management Network Commercial |
$84.84
|
| Rate for Payer: Health Management Network Commercial |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$83.82
|
| Rate for Payer: Health Management Network Commercial |
$83.22
|
| Rate for Payer: Health Management Network Commercial |
$15.31
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Humana Medicare |
$21.89
|
| Rate for Payer: Humana Medicare |
$49.91
|
| Rate for Payer: Humana Medicare |
$9.01
|
| Rate for Payer: Humana Medicare |
$48.95
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.11
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.83
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$88.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$50.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$49.91
|
| Rate for Payer: MDX Hawaii PPO |
$96.82
|
| Rate for Payer: MDX Hawaii PPO |
$17.47
|
| Rate for Payer: MDX Hawaii PPO |
$94.96
|
| Rate for Payer: MDX Hawaii PPO |
$95.65
|
| Rate for Payer: MDX Hawaii PPO |
$42.46
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$49.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.89
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$49.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.89
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$59.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$58.74
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$49.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.95
|
| Rate for Payer: University Health Alliance Commercial |
$13.13
|
| Rate for Payer: University Health Alliance Commercial |
$71.36
|
| Rate for Payer: University Health Alliance Commercial |
$71.88
|
| Rate for Payer: University Health Alliance Commercial |
$72.75
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$31.90
|
|
|
vancomycin 1250 mg vial [HHSC]
|
Facility
|
OP
|
$118.97
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
2501191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$115.40 |
| Rate for Payer: AlohaCare Medicaid |
$59.48
|
| Rate for Payer: AlohaCare Medicare |
$59.48
|
| Rate for Payer: Cash Price |
$77.33
|
| Rate for Payer: Cash Price |
$77.33
|
| Rate for Payer: Devoted Health Medicare |
$65.43
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$8.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$8.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$113.02
|
| Rate for Payer: Health Management Network Commercial |
$101.12
|
| Rate for Payer: Humana Medicare |
$59.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.07
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.48
|
| Rate for Payer: MDX Hawaii PPO |
$115.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.48
|
| Rate for Payer: University Health Alliance Commercial |
$86.72
|
|
|
vancomycin 1250 mg vial [HHSC]
|
Facility
|
IP
|
$118.97
|
|
|
Service Code
|
HCPCS J3370
|
| Hospital Charge Code |
2501191
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.12 |
| Max. Negotiated Rate |
$115.40 |
| Rate for Payer: Cash Price |
$77.33
|
| Rate for Payer: Health Management Network Commercial |
$101.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.07
|
| Rate for Payer: MDX Hawaii PPO |
$115.40
|
|
|
vancomycin 125 mg capsule [HHSC]
|
Facility
|
IP
|
$149.17
|
|
|
Service Code
|
NDC 68180016613
|
| Hospital Charge Code |
2500847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.79 |
| Max. Negotiated Rate |
$144.69 |
| Rate for Payer: Cash Price |
$96.96
|
| Rate for Payer: Health Management Network Commercial |
$126.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.25
|
| Rate for Payer: MDX Hawaii PPO |
$144.69
|
|
|
vancomycin 125 mg capsule [HHSC]
|
Facility
|
IP
|
$149.01
|
|
|
Service Code
|
NDC 00121086720
|
| Hospital Charge Code |
2500847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.66 |
| Max. Negotiated Rate |
$144.54 |
| Rate for Payer: Cash Price |
$96.86
|
| Rate for Payer: Health Management Network Commercial |
$126.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.11
|
| Rate for Payer: MDX Hawaii PPO |
$144.54
|
|
|
vancomycin 125 mg capsule [HHSC]
|
Facility
|
IP
|
$149.01
|
|
|
Service Code
|
NDC 42494045020
|
| Hospital Charge Code |
2500847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.66 |
| Max. Negotiated Rate |
$144.54 |
| Rate for Payer: Cash Price |
$96.86
|
| Rate for Payer: Health Management Network Commercial |
$126.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.11
|
| Rate for Payer: MDX Hawaii PPO |
$144.54
|
|
|
vancomycin 125 mg capsule [HHSC]
|
Facility
|
OP
|
$149.17
|
|
|
Service Code
|
NDC 68180016613
|
| Hospital Charge Code |
2500847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.58 |
| Max. Negotiated Rate |
$144.69 |
| Rate for Payer: AlohaCare Medicaid |
$74.58
|
| Rate for Payer: AlohaCare Medicare |
$74.58
|
| Rate for Payer: Cash Price |
$96.96
|
| Rate for Payer: Devoted Health Medicare |
$82.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.71
|
| Rate for Payer: Health Management Network Commercial |
$126.79
|
| Rate for Payer: Humana Medicare |
$74.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.58
|
| Rate for Payer: MDX Hawaii PPO |
$144.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.58
|
| Rate for Payer: University Health Alliance Commercial |
$108.73
|
|
|
vancomycin 125 mg capsule [HHSC]
|
Facility
|
OP
|
$149.01
|
|
|
Service Code
|
NDC 00121086720
|
| Hospital Charge Code |
2500847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.50 |
| Max. Negotiated Rate |
$144.54 |
| Rate for Payer: AlohaCare Medicaid |
$74.50
|
| Rate for Payer: AlohaCare Medicare |
$74.50
|
| Rate for Payer: Cash Price |
$96.86
|
| Rate for Payer: Devoted Health Medicare |
$81.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.56
|
| Rate for Payer: Health Management Network Commercial |
$126.66
|
| Rate for Payer: Humana Medicare |
$74.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.50
|
| Rate for Payer: MDX Hawaii PPO |
$144.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.50
|
| Rate for Payer: University Health Alliance Commercial |
$108.61
|
|
|
vancomycin 125 mg capsule [HHSC]
|
Facility
|
OP
|
$149.01
|
|
|
Service Code
|
NDC 42494045020
|
| Hospital Charge Code |
2500847
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.50 |
| Max. Negotiated Rate |
$144.54 |
| Rate for Payer: AlohaCare Medicaid |
$74.50
|
| Rate for Payer: AlohaCare Medicare |
$74.50
|
| Rate for Payer: Cash Price |
$96.86
|
| Rate for Payer: Devoted Health Medicare |
$81.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.56
|
| Rate for Payer: Health Management Network Commercial |
$126.66
|
| Rate for Payer: Humana Medicare |
$74.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.50
|
| Rate for Payer: MDX Hawaii PPO |
$144.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.50
|
| Rate for Payer: University Health Alliance Commercial |
$108.61
|
|
|
vancomycin 1500mg/300mL-SWFI premix [HHSC]
|
Facility
|
IP
|
$133.52
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
2501012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$113.49 |
| Max. Negotiated Rate |
$129.51 |
| Rate for Payer: Cash Price |
$86.79
|
| Rate for Payer: Health Management Network Commercial |
$113.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$120.17
|
| Rate for Payer: MDX Hawaii PPO |
$129.51
|
|
|
vancomycin 1500mg/300mL-SWFI premix [HHSC]
|
Facility
|
OP
|
$133.52
|
|
|
Service Code
|
HCPCS J3375
|
| Hospital Charge Code |
2501012
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$129.51 |
| Rate for Payer: AlohaCare Medicaid |
$66.76
|
| Rate for Payer: AlohaCare Medicare |
$66.76
|
| Rate for Payer: Cash Price |
$86.79
|
| Rate for Payer: Cash Price |
$86.79
|
| Rate for Payer: Devoted Health Medicare |
$73.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$126.84
|
| Rate for Payer: Health Management Network Commercial |
$113.49
|
| Rate for Payer: Humana Medicare |
$66.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$120.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$68.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.76
|
| Rate for Payer: MDX Hawaii PPO |
$129.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$80.11
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.76
|
| Rate for Payer: University Health Alliance Commercial |
$97.32
|
|
