|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904585561
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
IBUPROFEN 800 MG TABLET [3845]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904585561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
IBUPROFEN SUSPENSION (MOTRIN) 100 MG/5 ML (120 ML) (TAKE HOME) [4080367]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080155
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
IBUPROFEN SUSPENSION (MOTRIN) 100 MG/5 ML (120 ML) (TAKE HOME) [4080367]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080155
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
IBUPROFEN TABLETS (MOTRIN) 400 MG (TAKE HOME) [4080368]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080156
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
IBUPROFEN TABLETS (MOTRIN) 400 MG (TAKE HOME) [4080368]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080156
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE [191015]
|
Facility
|
IP
|
$13,209.00
|
|
|
Service Code
|
HCPCS J1744
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,227.65 |
| Max. Negotiated Rate |
$12,812.73 |
| Rate for Payer: Cash Price |
$7,925.40
|
| Rate for Payer: Health Management Network Commercial |
$11,227.65
|
| Rate for Payer: MDX Hawaii PPO |
$12,812.73
|
|
|
ICD EVERA MRI XT DDMB1D1
|
Facility
|
OP
|
$43,890.00
|
|
|
Service Code
|
HCPCS C1721
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,383.90 |
| Max. Negotiated Rate |
$42,573.30 |
| Rate for Payer: Cash Price |
$26,334.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30,723.00
|
| Rate for Payer: Health Management Network Commercial |
$37,306.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$27,650.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22,383.90
|
| Rate for Payer: MDX Hawaii PPO |
$42,573.30
|
| Rate for Payer: University Health Alliance Commercial |
$24,578.40
|
|
|
ICD EVERA MRI XT DDMB1D1
|
Facility
|
IP
|
$43,890.00
|
|
|
Service Code
|
HCPCS C1721
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$24,578.40 |
| Max. Negotiated Rate |
$42,573.30 |
| Rate for Payer: Cash Price |
$26,334.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30,723.00
|
| Rate for Payer: Health Management Network Commercial |
$37,306.50
|
| Rate for Payer: MDX Hawaii PPO |
$42,573.30
|
| Rate for Payer: University Health Alliance Commercial |
$24,578.40
|
|
|
ICEFORCE CRYO NEEDLE
|
Facility
|
OP
|
$3,790.00
|
|
|
Service Code
|
HCPCS C2618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,932.90 |
| Max. Negotiated Rate |
$3,676.30 |
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,600.50
|
| Rate for Payer: Health Management Network Commercial |
$3,221.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,387.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,932.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,676.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,762.53
|
|
|
ICEFORCE CRYO NEEDLE
|
Facility
|
IP
|
$3,790.00
|
|
|
Service Code
|
HCPCS C2618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,221.50 |
| Max. Negotiated Rate |
$3,676.30 |
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Health Management Network Commercial |
$3,221.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,676.30
|
|
|
ICEPEARL CRYO NEEDLE
|
Facility
|
IP
|
$3,790.00
|
|
|
Service Code
|
HCPCS C2618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,221.50 |
| Max. Negotiated Rate |
$3,676.30 |
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Health Management Network Commercial |
$3,221.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,676.30
|
|
|
ICEPEARL CRYO NEEDLE
|
Facility
|
OP
|
$3,790.00
|
|
|
Service Code
|
HCPCS C2618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,932.90 |
| Max. Negotiated Rate |
$3,676.30 |
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,600.50
|
| Rate for Payer: Health Management Network Commercial |
$3,221.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,387.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,932.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,676.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,762.53
|
|
|
ICEROD CRYO NEEDLE
|
Facility
|
OP
|
$3,790.00
|
|
|
Service Code
|
HCPCS C2618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,932.90 |
| Max. Negotiated Rate |
$3,676.30 |
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,600.50
|
| Rate for Payer: Health Management Network Commercial |
$3,221.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,387.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,932.90
|
| Rate for Payer: MDX Hawaii PPO |
$3,676.30
|
| Rate for Payer: University Health Alliance Commercial |
$2,762.53
|
|
|
ICEROD CRYO NEEDLE
|
Facility
|
IP
|
$3,790.00
|
|
|
Service Code
|
HCPCS C2618
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,221.50 |
| Max. Negotiated Rate |
$3,676.30 |
| Rate for Payer: Cash Price |
$2,274.00
|
| Rate for Payer: Health Management Network Commercial |
$3,221.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,676.30
|
|
|
ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 52937000120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
|
|
ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 60687076411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.60 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
|
|
ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 52937000120
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$12.61 |
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.35
|
| Rate for Payer: Health Management Network Commercial |
$11.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.63
|
| Rate for Payer: MDX Hawaii PPO |
$12.61
|
| Rate for Payer: University Health Alliance Commercial |
$9.48
|
|
|
ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00054050823
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.56
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 60687076411
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.16 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.20
|
| Rate for Payer: Health Management Network Commercial |
$13.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.16
|
| Rate for Payer: MDX Hawaii PPO |
$15.52
|
| Rate for Payer: University Health Alliance Commercial |
$11.66
|
|
|
ICOSAPENT ETHYL 1 GRAM CAPSULE [119049]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00054050823
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [130445]
|
Facility
|
OP
|
$6,123.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,122.73 |
| Max. Negotiated Rate |
$5,939.31 |
| Rate for Payer: Cash Price |
$3,673.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,816.85
|
| Rate for Payer: Health Management Network Commercial |
$5,204.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,857.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,122.73
|
| Rate for Payer: MDX Hawaii PPO |
$5,939.31
|
| Rate for Payer: University Health Alliance Commercial |
$4,463.05
|
|
|
IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION [130445]
|
Facility
|
IP
|
$6,123.00
|
|
|
Service Code
|
HCPCS J3490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,204.55 |
| Max. Negotiated Rate |
$5,939.31 |
| Rate for Payer: Cash Price |
$3,673.80
|
| Rate for Payer: Health Management Network Commercial |
$5,204.55
|
| Rate for Payer: MDX Hawaii PPO |
$5,939.31
|
|
|
IDURSULFASE 6 MG/3 ML INTRAVENOUS SOLUTION [76878]
|
Facility
|
OP
|
$4,376.00
|
|
|
Service Code
|
HCPCS J1743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$558.22 |
| Max. Negotiated Rate |
$4,244.72 |
| Rate for Payer: AlohaCare Medicaid |
$558.22
|
| Rate for Payer: AlohaCare Medicare |
$558.22
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Devoted Health Medicare |
$614.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$558.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$697.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$558.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$558.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,157.20
|
| Rate for Payer: Health Management Network Commercial |
$3,719.60
|
| Rate for Payer: Humana Medicare |
$558.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,756.88
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,231.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$558.22
|
| Rate for Payer: MDX Hawaii PPO |
$4,244.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$614.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$558.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,625.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$558.22
|
| Rate for Payer: University Health Alliance Commercial |
$3,189.67
|
|
|
IDURSULFASE 6 MG/3 ML INTRAVENOUS SOLUTION [76878]
|
Facility
|
IP
|
$4,376.00
|
|
|
Service Code
|
HCPCS J1743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,719.60 |
| Max. Negotiated Rate |
$4,244.72 |
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Health Management Network Commercial |
$3,719.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,244.72
|
|
