|
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: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
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: Kaiser Permanente Commercial |
$5,510.70
|
| Rate for Payer: MDX Hawaii PPO |
$5,939.31
|
|
|
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 |
$3,061.50 |
| Max. Negotiated Rate |
$5,939.31 |
| Rate for Payer: AlohaCare Medicaid |
$3,061.50
|
| Rate for Payer: AlohaCare Medicare |
$4,653.48
|
| Rate for Payer: Cash Price |
$3,673.80
|
| Rate for Payer: Devoted Health Medicare |
$5,143.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,653.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,816.85
|
| Rate for Payer: Health Management Network Commercial |
$5,204.55
|
| Rate for Payer: Humana Medicare |
$4,653.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,510.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,122.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,653.48
|
| Rate for Payer: MDX Hawaii PPO |
$5,939.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,653.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,653.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,653.48
|
| Rate for Payer: University Health Alliance Commercial |
$4,463.05
|
|
|
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: Kaiser Permanente Commercial |
$3,938.40
|
| Rate for Payer: MDX Hawaii PPO |
$4,244.72
|
|
|
IDURSULFASE 6 MG/3 ML INTRAVENOUS SOLUTION [76878]
|
Facility
|
OP
|
$4,376.00
|
|
|
Service Code
|
HCPCS J1743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$558.56 |
| Max. Negotiated Rate |
$4,244.72 |
| Rate for Payer: AlohaCare Medicaid |
$2,188.00
|
| Rate for Payer: AlohaCare Medicare |
$3,325.76
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Cash Price |
$2,625.60
|
| Rate for Payer: Devoted Health Medicare |
$3,675.84
|
| 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 |
$3,325.76
|
| 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 |
$3,325.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,938.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,231.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,325.76
|
| Rate for Payer: MDX Hawaii PPO |
$4,244.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,325.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,325.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,625.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,325.76
|
| Rate for Payer: University Health Alliance Commercial |
$3,189.67
|
|
|
IFOSFAMIDE 3 G/60ML IV (WET SOLR VIAL) [43010249]
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS J9208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.75 |
| Max. Negotiated Rate |
$111.55 |
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Health Management Network Commercial |
$164.90
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.60
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: MDX Hawaii PPO |
$188.18
|
|
|
IFOSFAMIDE 3 G/60ML IV (WET SOLR VIAL) [43010249]
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS J9208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$188.18 |
| Rate for Payer: AlohaCare Medicaid |
$97.00
|
| Rate for Payer: AlohaCare Medicaid |
$57.50
|
| Rate for Payer: AlohaCare Medicare |
$87.40
|
| Rate for Payer: AlohaCare Medicare |
$147.44
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Devoted Health Medicare |
$96.60
|
| Rate for Payer: Devoted Health Medicare |
$162.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$184.30
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Health Management Network Commercial |
$164.90
|
| Rate for Payer: Humana Medicare |
$87.40
|
| Rate for Payer: Humana Medicare |
$147.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.44
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: MDX Hawaii PPO |
$188.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$147.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$69.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$116.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.40
|
| Rate for Payer: University Health Alliance Commercial |
$83.82
|
| Rate for Payer: University Health Alliance Commercial |
$141.41
|
|
|
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS J9208
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$164.90 |
| Max. Negotiated Rate |
$188.18 |
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Health Management Network Commercial |
$164.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.60
|
| Rate for Payer: MDX Hawaii PPO |
$188.18
|
|
|
IFOSFAMIDE 3 GRAM INTRAVENOUS SOLUTION [10249]
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS J9208
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.50 |
| Max. Negotiated Rate |
$188.18 |
| Rate for Payer: AlohaCare Medicaid |
$97.00
|
| Rate for Payer: AlohaCare Medicare |
$147.44
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Cash Price |
$116.40
|
| Rate for Payer: Devoted Health Medicare |
$162.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$23.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$147.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$23.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$184.30
|
| Rate for Payer: Health Management Network Commercial |
$164.90
|
| Rate for Payer: Humana Medicare |
$147.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$174.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$98.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$147.44
|
| Rate for Payer: MDX Hawaii PPO |
$188.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$147.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$147.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$116.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$147.44
|
| Rate for Payer: University Health Alliance Commercial |
$141.41
|
|
|
ILIAC EXTENDER ENDOPROSTHESIS
|
Facility
|
OP
|
$6,200.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,100.00 |
| Max. Negotiated Rate |
$6,014.00 |
| Rate for Payer: AlohaCare Medicaid |
$3,100.00
|
| Rate for Payer: AlohaCare Medicare |
$4,712.00
|
| Rate for Payer: Cash Price |
$3,720.00
|
| Rate for Payer: Devoted Health Medicare |
$5,208.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,712.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,340.00
|
| Rate for Payer: Health Management Network Commercial |
$5,270.00
|
| Rate for Payer: Humana Medicare |
$4,712.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,580.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,162.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,712.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,014.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,712.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,712.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,712.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,472.00
|
|
|
ILIAC EXTENDER ENDOPROSTHESIS
|
Facility
|
IP
|
$6,200.00
|
|
|
Service Code
|
HCPCS C1768
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.00 |
| Max. Negotiated Rate |
$6,014.00 |
| Rate for Payer: Cash Price |
$3,720.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,340.00
|
| Rate for Payer: Health Management Network Commercial |
$5,270.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,580.00
|
| Rate for Payer: MDX Hawaii PPO |
$6,014.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,472.00
|
|
|
ILIVIA 7 DEFIBRILLATOR 404625
|
Facility
|
IP
|
$33,900.00
|
|
|
Service Code
|
HCPCS C1722
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$18,984.00 |
| Max. Negotiated Rate |
$32,883.00 |
| Rate for Payer: Cash Price |
$20,340.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23,730.00
|
| Rate for Payer: Health Management Network Commercial |
$28,815.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,510.00
|
| Rate for Payer: MDX Hawaii PPO |
$32,883.00
|
| Rate for Payer: University Health Alliance Commercial |
$18,984.00
|
|
|
ILIVIA 7 DEFIBRILLATOR 404625
|
Facility
|
OP
|
$33,900.00
|
|
|
Service Code
|
HCPCS C1722
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$16,950.00 |
| Max. Negotiated Rate |
$32,883.00 |
| Rate for Payer: AlohaCare Medicaid |
$16,950.00
|
| Rate for Payer: AlohaCare Medicare |
$25,764.00
|
| Rate for Payer: Cash Price |
$20,340.00
|
| Rate for Payer: Devoted Health Medicare |
$28,476.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25,764.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23,730.00
|
| Rate for Payer: Health Management Network Commercial |
$28,815.00
|
| Rate for Payer: Humana Medicare |
$25,764.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$30,510.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17,289.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$25,764.00
|
| Rate for Payer: MDX Hawaii PPO |
$32,883.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25,764.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$25,764.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$25,764.00
|
| Rate for Payer: University Health Alliance Commercial |
$18,984.00
|
|
|
IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL) [4309603]
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
IMIPENEM-CILASTATIN 500 MG/10ML IV (WET SOLR VIAL) [4309603]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicaid |
$53.00
|
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$68.40
|
| Rate for Payer: AlohaCare Medicare |
$80.56
|
| Rate for Payer: AlohaCare Medicare |
$31.92
|
| Rate for Payer: AlohaCare Medicare |
$63.08
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Devoted Health Medicare |
$69.72
|
| Rate for Payer: Devoted Health Medicare |
$35.28
|
| Rate for Payer: Devoted Health Medicare |
$75.60
|
| Rate for Payer: Devoted Health Medicare |
$89.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$80.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.92
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Humana Medicare |
$80.56
|
| Rate for Payer: Humana Medicare |
$63.08
|
| Rate for Payer: Humana Medicare |
$31.92
|
| Rate for Payer: Humana Medicare |
$68.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.92
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$80.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$80.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$80.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.92
|
| Rate for Payer: University Health Alliance Commercial |
$77.26
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$70.55 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
|
|
IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION [9603]
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS J0743
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.97 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicaid |
$45.00
|
| Rate for Payer: AlohaCare Medicare |
$68.40
|
| Rate for Payer: AlohaCare Medicare |
$63.08
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Devoted Health Medicare |
$69.72
|
| Rate for Payer: Devoted Health Medicare |
$75.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$85.50
|
| Rate for Payer: Health Management Network Commercial |
$76.50
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Humana Medicare |
$63.08
|
| Rate for Payer: Humana Medicare |
$68.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$81.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.40
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$87.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.40
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
| Rate for Payer: University Health Alliance Commercial |
$65.60
|
|
|
IMMOBILIZER KNEE 16
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$70.50 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: AlohaCare Medicaid |
$70.50
|
| Rate for Payer: AlohaCare Medicare |
$107.16
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Devoted Health Medicare |
$118.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.70
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Humana Medicare |
$107.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$107.16
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$107.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.16
|
| Rate for Payer: University Health Alliance Commercial |
$78.96
|
|
|
IMMOBILIZER KNEE 16
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$78.96 |
| Max. Negotiated Rate |
$136.77 |
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.70
|
| Rate for Payer: Health Management Network Commercial |
$119.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.90
|
| Rate for Payer: MDX Hawaii PPO |
$136.77
|
| Rate for Payer: University Health Alliance Commercial |
$78.96
|
|
|
IMMOBILIZER KNEE 20
|
Facility
|
OP
|
$87.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$87.51 |
| Rate for Payer: AlohaCare Medicaid |
$43.50
|
| Rate for Payer: AlohaCare Medicare |
$66.12
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Devoted Health Medicare |
$73.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.90
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Humana Medicare |
$66.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.12
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.12
|
| Rate for Payer: University Health Alliance Commercial |
$48.72
|
|
|
IMMOBILIZER KNEE 20
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$48.72 |
| Max. Negotiated Rate |
$84.39 |
| Rate for Payer: Cash Price |
$52.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$60.90
|
| Rate for Payer: Health Management Network Commercial |
$73.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.30
|
| Rate for Payer: MDX Hawaii PPO |
$84.39
|
| Rate for Payer: University Health Alliance Commercial |
$48.72
|
|
|
IMMOBILIZER KNEE 22
|
Facility
|
IP
|
$103.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$57.68 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.10
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: University Health Alliance Commercial |
$57.68
|
|
|
IMMOBILIZER KNEE 22
|
Facility
|
OP
|
$103.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$51.50 |
| Max. Negotiated Rate |
$99.91 |
| Rate for Payer: AlohaCare Medicaid |
$51.50
|
| Rate for Payer: AlohaCare Medicare |
$78.28
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Devoted Health Medicare |
$86.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.10
|
| Rate for Payer: Health Management Network Commercial |
$87.55
|
| Rate for Payer: Humana Medicare |
$78.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$52.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.28
|
| Rate for Payer: MDX Hawaii PPO |
$99.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.28
|
| Rate for Payer: University Health Alliance Commercial |
$57.68
|
|
|
IMMOBILIZER KNEE 24
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$47.00 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: AlohaCare Medicaid |
$47.00
|
| Rate for Payer: AlohaCare Medicare |
$71.44
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Devoted Health Medicare |
$78.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.80
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Humana Medicare |
$71.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$47.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.44
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$87.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.44
|
| Rate for Payer: University Health Alliance Commercial |
$52.64
|
|
|
IMMOBILIZER KNEE 24
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
HCPCS L1830
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$52.64 |
| Max. Negotiated Rate |
$91.18 |
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$65.80
|
| Rate for Payer: Health Management Network Commercial |
$79.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.60
|
| Rate for Payer: MDX Hawaii PPO |
$91.18
|
| Rate for Payer: University Health Alliance Commercial |
$52.64
|
|
