|
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION [3990]
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
HCPCS J1750
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$95.20 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
|
|
IRON SUCROSE 100 MG IN 50 ML NS IVPB-CNR (SIMPLE) [4080034]
|
Facility
|
IP
|
$274.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$232.90 |
| Max. Negotiated Rate |
$265.78 |
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Health Management Network Commercial |
$232.90
|
| Rate for Payer: MDX Hawaii PPO |
$265.78
|
|
|
IRON SUCROSE 100 MG IN 50 ML NS IVPB-CNR (SIMPLE) [4080034]
|
Facility
|
OP
|
$274.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$265.78 |
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$260.30
|
| Rate for Payer: Health Management Network Commercial |
$232.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$172.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$139.74
|
| Rate for Payer: MDX Hawaii PPO |
$265.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$164.40
|
| Rate for Payer: University Health Alliance Commercial |
$199.72
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$165.75 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$81.48 |
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$185.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$79.80
|
| Rate for Payer: Health Management Network Commercial |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$165.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$117.00
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
|
|
IRON SUCROSE 200 MG IN 100 ML NS IVPB-CNR (SIMPLE) [4080036]
|
Facility
|
OP
|
$547.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$530.59 |
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.22
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$519.65
|
| Rate for Payer: Health Management Network Commercial |
$464.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$344.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$278.97
|
| Rate for Payer: MDX Hawaii PPO |
$530.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$328.20
|
| Rate for Payer: University Health Alliance Commercial |
$398.71
|
|
|
IRON SUCROSE 200 MG IN 100 ML NS IVPB-CNR (SIMPLE) [4080036]
|
Facility
|
IP
|
$547.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$464.95 |
| Max. Negotiated Rate |
$530.59 |
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Health Management Network Commercial |
$464.95
|
| Rate for Payer: MDX Hawaii PPO |
$530.59
|
|
|
IS-1 RECEPTACLE PLUG AC-IP-2
|
Facility
|
IP
|
$175.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$169.75 |
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.50
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
| Rate for Payer: University Health Alliance Commercial |
$98.00
|
|
|
IS-1 RECEPTACLE PLUG AC-IP-2
|
Facility
|
OP
|
$175.00
|
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$169.75 |
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.50
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$110.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.25
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
| Rate for Payer: University Health Alliance Commercial |
$98.00
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [172102]
|
Facility
|
IP
|
$1,566.00
|
|
|
Service Code
|
HCPCS J9227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,331.10 |
| Max. Negotiated Rate |
$1,519.02 |
| Rate for Payer: Cash Price |
$4,698.00
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Health Management Network Commercial |
$1,331.10
|
| Rate for Payer: Health Management Network Commercial |
$6,655.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,519.02
|
| Rate for Payer: MDX Hawaii PPO |
$7,595.10
|
|
|
ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION [172102]
|
Facility
|
OP
|
$1,566.00
|
|
|
Service Code
|
HCPCS J9227
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.86 |
| Max. Negotiated Rate |
$1,519.02 |
| Rate for Payer: AlohaCare Medicaid |
$83.58
|
| Rate for Payer: AlohaCare Medicaid |
$83.58
|
| Rate for Payer: AlohaCare Medicare |
$83.58
|
| Rate for Payer: AlohaCare Medicare |
$83.58
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cash Price |
$4,698.00
|
| Rate for Payer: Cash Price |
$939.60
|
| Rate for Payer: Cash Price |
$4,698.00
|
| Rate for Payer: Devoted Health Medicare |
$91.94
|
| Rate for Payer: Devoted Health Medicare |
$91.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$82.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$82.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$104.47
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$104.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$82.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$82.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,487.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,438.50
|
| Rate for Payer: Health Management Network Commercial |
$6,655.50
|
| Rate for Payer: Health Management Network Commercial |
$1,331.10
|
| Rate for Payer: Humana Medicare |
$83.58
|
| Rate for Payer: Humana Medicare |
$83.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$986.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,932.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$798.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,993.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.58
|
| Rate for Payer: MDX Hawaii PPO |
$1,519.02
|
| Rate for Payer: MDX Hawaii PPO |
$7,595.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$91.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$939.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,698.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.58
|
| Rate for Payer: University Health Alliance Commercial |
$1,141.46
|
| Rate for Payer: University Health Alliance Commercial |
$5,707.29
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC
|
Facility
|
IP
|
$52,026.30
|
|
|
Service Code
|
MSDRG 062
|
| Min. Negotiated Rate |
$19,986.85 |
| Max. Negotiated Rate |
$52,026.30 |
| Rate for Payer: AlohaCare Medicare |
$19,986.85
|
| Rate for Payer: Devoted Health Medicare |
$21,985.53
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$52,026.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19,986.85
|
| Rate for Payer: Humana Medicare |
$19,986.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,311.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$19,986.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$19,986.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$19,986.85
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC
|
Facility
|
IP
|
$52,026.30
|
|
|
Service Code
|
MSDRG 061
|
| Min. Negotiated Rate |
$31,359.96 |
| Max. Negotiated Rate |
$52,026.30 |
| Rate for Payer: AlohaCare Medicare |
$31,359.96
|
| Rate for Payer: Devoted Health Medicare |
$34,495.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$52,026.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31,359.96
|
| Rate for Payer: Humana Medicare |
$31,359.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$47,559.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$31,359.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$31,359.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$31,359.96
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC
|
Facility
|
IP
|
$52,026.30
|
|
|
Service Code
|
MSDRG 063
|
| Min. Negotiated Rate |
$15,967.18 |
| Max. Negotiated Rate |
$52,026.30 |
| Rate for Payer: AlohaCare Medicare |
$15,967.18
|
| Rate for Payer: Devoted Health Medicare |
$17,563.90
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$52,026.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15,967.18
|
| Rate for Payer: Humana Medicare |
$15,967.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$24,215.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$15,967.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$15,967.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$15,967.18
|
|
|
ISOFLEX PACING LEAD 1948-58CM
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$945.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$765.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
|
ISOFLEX PACING LEAD 1948-58CM
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00555007101
|
|
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
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 64950021710
|
|
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
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00555007101
|
|
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
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00555007102
|
|
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
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00555007102
|
|
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
|
|
|
ISONIAZID 300 MG TABLET [4027]
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 64950021710
|
|
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
|
|
|
ISONIAZID 50 MG/5 ML ORAL SOLUTION [4025]
|
Facility
|
OP
|
$695.00
|
|
|
Service Code
|
NDC 46287000901
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$354.45 |
| Max. Negotiated Rate |
$674.15 |
| Rate for Payer: Cash Price |
$417.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$660.25
|
| Rate for Payer: Health Management Network Commercial |
$590.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$437.85
|
| Rate for Payer: Kaiser Permanente Medicaid |
$354.45
|
| Rate for Payer: MDX Hawaii PPO |
$674.15
|
| Rate for Payer: University Health Alliance Commercial |
$506.59
|
|
|
ISONIAZID 50 MG/5 ML ORAL SOLUTION [4025]
|
Facility
|
IP
|
$695.00
|
|
|
Service Code
|
NDC 46287000901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$590.75 |
| Max. Negotiated Rate |
$674.15 |
| Rate for Payer: Cash Price |
$417.00
|
| Rate for Payer: Health Management Network Commercial |
$590.75
|
| Rate for Payer: MDX Hawaii PPO |
$674.15
|
|
|
ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION [4034]
|
Facility
|
IP
|
$420.00
|
|
|
Service Code
|
NDC 69918073510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$357.00 |
| Max. Negotiated Rate |
$407.40 |
| Rate for Payer: Cash Price |
$252.00
|
| Rate for Payer: Health Management Network Commercial |
$357.00
|
| Rate for Payer: MDX Hawaii PPO |
$407.40
|
|
