|
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION [108956]
|
Facility
|
OP
|
$43,963.00
|
|
|
Service Code
|
HCPCS J9228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.41 |
| Max. Negotiated Rate |
$42,644.11 |
| Rate for Payer: AlohaCare Medicaid |
$21,981.50
|
| Rate for Payer: AlohaCare Medicaid |
$14,267.00
|
| Rate for Payer: AlohaCare Medicare |
$21,685.84
|
| Rate for Payer: AlohaCare Medicare |
$33,411.88
|
| Rate for Payer: Cash Price |
$26,377.80
|
| Rate for Payer: Cash Price |
$17,120.40
|
| Rate for Payer: Cash Price |
$17,120.40
|
| Rate for Payer: Cash Price |
$26,377.80
|
| Rate for Payer: Devoted Health Medicare |
$36,928.92
|
| Rate for Payer: Devoted Health Medicare |
$23,968.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$183.41
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$183.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$233.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$233.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21,685.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33,411.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$183.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$183.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27,107.30
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41,764.85
|
| Rate for Payer: Health Management Network Commercial |
$24,253.90
|
| Rate for Payer: Health Management Network Commercial |
$37,368.55
|
| Rate for Payer: Humana Medicare |
$33,411.88
|
| Rate for Payer: Humana Medicare |
$21,685.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$25,680.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$39,566.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14,552.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22,421.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$21,685.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$33,411.88
|
| Rate for Payer: MDX Hawaii PPO |
$27,677.98
|
| Rate for Payer: MDX Hawaii PPO |
$42,644.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33,411.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21,685.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$21,685.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$33,411.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17,120.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26,377.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$21,685.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$33,411.88
|
| Rate for Payer: University Health Alliance Commercial |
$32,044.63
|
| Rate for Payer: University Health Alliance Commercial |
$20,798.43
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]
|
Facility
|
OP
|
$11,366.00
|
|
|
Service Code
|
HCPCS J9228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$183.41 |
| Max. Negotiated Rate |
$11,025.02 |
| Rate for Payer: AlohaCare Medicaid |
$5,683.00
|
| Rate for Payer: AlohaCare Medicare |
$8,638.16
|
| Rate for Payer: Cash Price |
$6,819.60
|
| Rate for Payer: Cash Price |
$6,819.60
|
| Rate for Payer: Devoted Health Medicare |
$9,547.44
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$183.41
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$233.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,638.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$183.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,797.70
|
| Rate for Payer: Health Management Network Commercial |
$9,661.10
|
| Rate for Payer: Humana Medicare |
$8,638.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,229.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,796.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,638.16
|
| Rate for Payer: MDX Hawaii PPO |
$11,025.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,638.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,638.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,819.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,638.16
|
| Rate for Payer: University Health Alliance Commercial |
$8,284.68
|
|
|
IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]
|
Facility
|
IP
|
$11,366.00
|
|
|
Service Code
|
HCPCS J9228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,661.10 |
| Max. Negotiated Rate |
$11,025.02 |
| Rate for Payer: Cash Price |
$6,819.60
|
| Rate for Payer: Health Management Network Commercial |
$9,661.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,229.40
|
| Rate for Payer: MDX Hawaii PPO |
$11,025.02
|
|
|
IPRATROPIUM-ALBUTEROL 0.5-3 MG/3ML IN SOLN [93931]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J7620
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: AlohaCare Medicare |
$6.84
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Devoted Health Medicare |
$7.56
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.20
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Humana Medicare |
$6.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.84
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
IPRATROPIUM-ALBUTEROL 0.5-3 MG/3ML IN SOLN [93931]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J7620
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J7644
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J7644
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER [41142]
|
Facility
|
IP
|
$921.00
|
|
|
Service Code
|
NDC 00597008717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$782.85 |
| Max. Negotiated Rate |
$893.37 |
| Rate for Payer: Cash Price |
$552.60
|
| Rate for Payer: Health Management Network Commercial |
$782.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$828.90
|
| Rate for Payer: MDX Hawaii PPO |
$893.37
|
|
|
IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER [41142]
|
Facility
|
OP
|
$921.00
|
|
|
Service Code
|
NDC 00597008717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$460.50 |
| Max. Negotiated Rate |
$893.37 |
| Rate for Payer: AlohaCare Medicaid |
$460.50
|
| Rate for Payer: AlohaCare Medicare |
$699.96
|
| Rate for Payer: Cash Price |
$552.60
|
| Rate for Payer: Devoted Health Medicare |
$773.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$699.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$874.95
|
| Rate for Payer: Health Management Network Commercial |
$782.85
|
| Rate for Payer: Humana Medicare |
$699.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$828.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$469.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$699.96
|
| Rate for Payer: MDX Hawaii PPO |
$893.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$699.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$699.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$699.96
|
| Rate for Payer: University Health Alliance Commercial |
$671.32
|
|
|
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION [91054]
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
HCPCS J9206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$126.65 |
| Max. Negotiated Rate |
$144.53 |
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Health Management Network Commercial |
$126.65
|
| Rate for Payer: Health Management Network Commercial |
$280.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.00
|
| Rate for Payer: MDX Hawaii PPO |
$320.10
|
| Rate for Payer: MDX Hawaii PPO |
$144.53
|
|
|
IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION [91054]
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
HCPCS J9206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$144.53 |
| Rate for Payer: AlohaCare Medicaid |
$74.50
|
| Rate for Payer: AlohaCare Medicaid |
$165.00
|
| Rate for Payer: AlohaCare Medicare |
$250.80
|
| Rate for Payer: AlohaCare Medicare |
$113.24
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$89.40
|
| Rate for Payer: Cash Price |
$198.00
|
| Rate for Payer: Devoted Health Medicare |
$125.16
|
| Rate for Payer: Devoted Health Medicare |
$277.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$250.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$113.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$141.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$313.50
|
| Rate for Payer: Health Management Network Commercial |
$280.50
|
| Rate for Payer: Health Management Network Commercial |
$126.65
|
| Rate for Payer: Humana Medicare |
$113.24
|
| Rate for Payer: Humana Medicare |
$250.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$297.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$168.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$113.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$250.80
|
| Rate for Payer: MDX Hawaii PPO |
$144.53
|
| Rate for Payer: MDX Hawaii PPO |
$320.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$250.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$113.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$113.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$250.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$198.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$113.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$250.80
|
| Rate for Payer: University Health Alliance Commercial |
$108.61
|
| Rate for Payer: University Health Alliance Commercial |
$240.54
|
|
|
IRINOTECAN 300 MG/15 ML INTRAVENOUS SOLUTION [108138]
|
Facility
|
OP
|
$410.00
|
|
|
Service Code
|
HCPCS J9206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$397.70 |
| Rate for Payer: AlohaCare Medicaid |
$205.00
|
| Rate for Payer: AlohaCare Medicare |
$311.60
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Devoted Health Medicare |
$344.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$311.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$389.50
|
| Rate for Payer: Health Management Network Commercial |
$348.50
|
| Rate for Payer: Humana Medicare |
$311.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$369.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$209.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$311.60
|
| Rate for Payer: MDX Hawaii PPO |
$397.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$311.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$311.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$246.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$311.60
|
| Rate for Payer: University Health Alliance Commercial |
$298.85
|
|
|
IRINOTECAN 300 MG/15 ML INTRAVENOUS SOLUTION [108138]
|
Facility
|
IP
|
$410.00
|
|
|
Service Code
|
HCPCS J9206
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$348.50 |
| Max. Negotiated Rate |
$397.70 |
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Health Management Network Commercial |
$348.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$369.00
|
| Rate for Payer: MDX Hawaii PPO |
$397.70
|
|
|
IRINOTECAN 40 MG/2 ML INTRAVENOUS SOLUTION [91055]
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS J9206
|
|
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 |
$19.20
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
|
|
IRINOTECAN 40 MG/2 ML INTRAVENOUS SOLUTION [91055]
|
Facility
|
OP
|
$52.00
|
|
|
Service Code
|
HCPCS J9206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$50.44 |
| Rate for Payer: AlohaCare Medicaid |
$26.00
|
| Rate for Payer: AlohaCare Medicaid |
$26.50
|
| Rate for Payer: AlohaCare Medicaid |
$16.00
|
| Rate for Payer: AlohaCare Medicaid |
$41.50
|
| Rate for Payer: AlohaCare Medicare |
$63.08
|
| Rate for Payer: AlohaCare Medicare |
$24.32
|
| Rate for Payer: AlohaCare Medicare |
$39.52
|
| Rate for Payer: AlohaCare Medicare |
$40.28
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Devoted Health Medicare |
$44.52
|
| Rate for Payer: Devoted Health Medicare |
$43.68
|
| Rate for Payer: Devoted Health Medicare |
$69.72
|
| Rate for Payer: Devoted Health Medicare |
$26.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$78.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$30.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$49.40
|
| Rate for Payer: Health Management Network Commercial |
$45.05
|
| Rate for Payer: Health Management Network Commercial |
$27.20
|
| Rate for Payer: Health Management Network Commercial |
$44.20
|
| Rate for Payer: Health Management Network Commercial |
$70.55
|
| Rate for Payer: Humana Medicare |
$24.32
|
| Rate for Payer: Humana Medicare |
$40.28
|
| Rate for Payer: Humana Medicare |
$39.52
|
| Rate for Payer: Humana Medicare |
$63.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$46.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$27.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.52
|
| Rate for Payer: MDX Hawaii PPO |
$51.41
|
| Rate for Payer: MDX Hawaii PPO |
$31.04
|
| Rate for Payer: MDX Hawaii PPO |
$80.51
|
| Rate for Payer: MDX Hawaii PPO |
$50.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.32
|
| 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 |
$40.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$49.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.52
|
| Rate for Payer: University Health Alliance Commercial |
$23.32
|
| Rate for Payer: University Health Alliance Commercial |
$37.90
|
| Rate for Payer: University Health Alliance Commercial |
$38.63
|
| Rate for Payer: University Health Alliance Commercial |
$60.50
|
|
|
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS [130463]
|
Facility
|
OP
|
$13,241.00
|
|
|
Service Code
|
HCPCS J9205
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$12,843.77 |
| Rate for Payer: AlohaCare Medicaid |
$6,620.50
|
| Rate for Payer: AlohaCare Medicaid |
$2,748.00
|
| Rate for Payer: AlohaCare Medicare |
$4,176.96
|
| Rate for Payer: AlohaCare Medicare |
$10,063.16
|
| Rate for Payer: Cash Price |
$3,297.60
|
| Rate for Payer: Cash Price |
$7,944.60
|
| Rate for Payer: Cash Price |
$3,297.60
|
| Rate for Payer: Cash Price |
$7,944.60
|
| Rate for Payer: Devoted Health Medicare |
$11,122.44
|
| Rate for Payer: Devoted Health Medicare |
$4,616.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$65.26
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$65.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$82.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$82.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,176.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,063.16
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$65.26
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$65.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,578.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,221.20
|
| Rate for Payer: Health Management Network Commercial |
$4,671.60
|
| Rate for Payer: Health Management Network Commercial |
$11,254.85
|
| Rate for Payer: Humana Medicare |
$10,063.16
|
| Rate for Payer: Humana Medicare |
$4,176.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,916.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,946.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,802.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6,752.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,063.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,176.96
|
| Rate for Payer: MDX Hawaii PPO |
$12,843.77
|
| Rate for Payer: MDX Hawaii PPO |
$5,331.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,176.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,063.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,063.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,176.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,297.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,944.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,063.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,176.96
|
| Rate for Payer: University Health Alliance Commercial |
$9,651.36
|
| Rate for Payer: University Health Alliance Commercial |
$4,006.03
|
|
|
IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS [130463]
|
Facility
|
IP
|
$13,241.00
|
|
|
Service Code
|
HCPCS J9205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11,254.85 |
| Max. Negotiated Rate |
$12,843.77 |
| Rate for Payer: Cash Price |
$7,944.60
|
| Rate for Payer: Cash Price |
$3,297.60
|
| Rate for Payer: Health Management Network Commercial |
$11,254.85
|
| Rate for Payer: Health Management Network Commercial |
$4,671.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,916.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,946.40
|
| Rate for Payer: MDX Hawaii PPO |
$5,331.12
|
| Rate for Payer: MDX Hawaii PPO |
$12,843.77
|
|
|
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: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
|
|
IRON DEXTRAN 50 MG/ML INJECTION SOLUTION [3990]
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
HCPCS J1750
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$108.64 |
| Rate for Payer: AlohaCare Medicaid |
$56.00
|
| Rate for Payer: AlohaCare Medicare |
$85.12
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Devoted Health Medicare |
$94.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$22.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$18.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$106.40
|
| Rate for Payer: Health Management Network Commercial |
$95.20
|
| Rate for Payer: Humana Medicare |
$85.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.12
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.12
|
| Rate for Payer: University Health Alliance Commercial |
$81.64
|
|
|
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: AlohaCare Medicaid |
$137.00
|
| Rate for Payer: AlohaCare Medicare |
$208.24
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Devoted Health Medicare |
$230.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$208.24
|
| 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: Humana Medicare |
$208.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$139.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$208.24
|
| Rate for Payer: MDX Hawaii PPO |
$265.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$208.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$208.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$164.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$208.24
|
| Rate for Payer: University Health Alliance Commercial |
$199.72
|
|
|
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: Kaiser Permanente Commercial |
$246.60
|
| Rate for Payer: MDX Hawaii PPO |
$265.78
|
|
|
IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION [29132]
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS J1756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$189.15 |
| Rate for Payer: AlohaCare Medicaid |
$97.50
|
| Rate for Payer: AlohaCare Medicaid |
$42.00
|
| Rate for Payer: AlohaCare Medicare |
$63.84
|
| Rate for Payer: AlohaCare Medicare |
$148.20
|
| 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: Devoted Health Medicare |
$163.80
|
| Rate for Payer: Devoted Health Medicare |
$70.56
|
| 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 Medicare |
$63.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.20
|
| 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: Humana Medicare |
$148.20
|
| Rate for Payer: Humana Medicare |
$63.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$42.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$99.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$148.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$63.84
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$63.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$148.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$117.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$63.84
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
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: Kaiser Permanente Commercial |
$175.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$75.60
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
|
|
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: AlohaCare Medicaid |
$273.50
|
| Rate for Payer: AlohaCare Medicare |
$415.72
|
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Devoted Health Medicare |
$459.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$415.72
|
| 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: Humana Medicare |
$415.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$492.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$278.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$415.72
|
| Rate for Payer: MDX Hawaii PPO |
$530.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$415.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$415.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$328.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$415.72
|
| 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: Kaiser Permanente Commercial |
$492.30
|
| Rate for Payer: MDX Hawaii PPO |
$530.59
|
|
