|
IOLENS DIOP 17.5 SN6AT7 17.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 20.0 13.0 5.5MM
|
Facility
|
OP
|
$375.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$116.25 |
| Max. Negotiated Rate |
$363.75 |
| Rate for Payer: AlohaCare Medicaid |
$187.50
|
| Rate for Payer: AlohaCare Medicare |
$116.25
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Devoted Health Medicare |
$127.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$116.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$262.50
|
| Rate for Payer: Health Management Network Commercial |
$318.75
|
| Rate for Payer: Humana Medicare |
$116.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$337.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$191.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$116.25
|
| Rate for Payer: MDX Hawaii PPO |
$363.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$116.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$116.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$116.25
|
| Rate for Payer: University Health Alliance Commercial |
$210.00
|
|
|
IOLENS DIOP 20.0 13.0 5.5MM
|
Facility
|
IP
|
$375.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$363.75 |
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$262.50
|
| Rate for Payer: Health Management Network Commercial |
$318.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$337.50
|
| Rate for Payer: MDX Hawaii PPO |
$363.75
|
| Rate for Payer: University Health Alliance Commercial |
$210.00
|
|
|
IOLENS DIOP 20.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 20.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 23.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 23.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 8.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 8.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 9.5 SN6AT5 9.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS DIOP 9.5 SN6AT5 9.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS TORICE 27.5
|
Facility
|
IP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$970.48 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IOLENS TORICE 27.5
|
Facility
|
OP
|
$1,733.00
|
|
|
Service Code
|
HCPCS V2787
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$537.23 |
| Max. Negotiated Rate |
$1,681.01 |
| Rate for Payer: AlohaCare Medicaid |
$866.50
|
| Rate for Payer: AlohaCare Medicare |
$537.23
|
| Rate for Payer: Cash Price |
$1,039.80
|
| Rate for Payer: Devoted Health Medicare |
$589.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$537.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,213.10
|
| Rate for Payer: Health Management Network Commercial |
$1,473.05
|
| Rate for Payer: Humana Medicare |
$537.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,559.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$883.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$537.23
|
| Rate for Payer: MDX Hawaii PPO |
$1,681.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$537.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$537.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$537.23
|
| Rate for Payer: University Health Alliance Commercial |
$970.48
|
|
|
IPERIA PROMRI 7DR-T 392409
|
Facility
|
OP
|
$41,580.00
|
|
|
Service Code
|
HCPCS C1721
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$12,889.80 |
| Max. Negotiated Rate |
$40,332.60 |
| Rate for Payer: AlohaCare Medicaid |
$20,790.00
|
| Rate for Payer: AlohaCare Medicare |
$12,889.80
|
| Rate for Payer: Cash Price |
$24,948.00
|
| Rate for Payer: Devoted Health Medicare |
$14,137.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12,889.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29,106.00
|
| Rate for Payer: Health Management Network Commercial |
$35,343.00
|
| Rate for Payer: Humana Medicare |
$12,889.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$37,422.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21,205.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$12,889.80
|
| Rate for Payer: MDX Hawaii PPO |
$40,332.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12,889.80
|
| Rate for Payer: Ohana Health Plan Medicare |
$12,889.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$12,889.80
|
| Rate for Payer: University Health Alliance Commercial |
$23,284.80
|
|
|
IPERIA PROMRI 7DR-T 392409
|
Facility
|
IP
|
$41,580.00
|
|
|
Service Code
|
HCPCS C1721
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$23,284.80 |
| Max. Negotiated Rate |
$40,332.60 |
| Rate for Payer: Cash Price |
$24,948.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29,106.00
|
| Rate for Payer: Health Management Network Commercial |
$35,343.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37,422.00
|
| Rate for Payer: MDX Hawaii PPO |
$40,332.60
|
| Rate for Payer: University Health Alliance Commercial |
$23,284.80
|
|
|
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 |
$8,845.54
|
| Rate for Payer: AlohaCare Medicare |
$13,628.53
|
| 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 |
$14,947.42
|
| Rate for Payer: Devoted Health Medicare |
$9,701.56
|
| 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 |
$8,845.54
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13,628.53
|
| 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 |
$13,628.53
|
| Rate for Payer: Humana Medicare |
$8,845.54
|
| 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 |
$8,845.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$13,628.53
|
| 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 |
$13,628.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,845.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,845.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$13,628.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17,120.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26,377.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,845.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$13,628.53
|
| Rate for Payer: University Health Alliance Commercial |
$32,044.63
|
| Rate for Payer: University Health Alliance Commercial |
$20,798.43
|
|
|
IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION [108956]
|
Facility
|
IP
|
$43,963.00
|
|
|
Service Code
|
HCPCS J9228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37,368.55 |
| Max. Negotiated Rate |
$42,644.11 |
| Rate for Payer: Cash Price |
$26,377.80
|
| Rate for Payer: Cash Price |
$17,120.40
|
| Rate for Payer: Health Management Network Commercial |
$24,253.90
|
| Rate for Payer: Health Management Network Commercial |
$37,368.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$25,680.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$39,566.70
|
| Rate for Payer: MDX Hawaii PPO |
$42,644.11
|
| Rate for Payer: MDX Hawaii PPO |
$27,677.98
|
|
|
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 |
$3,523.46
|
| Rate for Payer: Cash Price |
$6,819.60
|
| Rate for Payer: Cash Price |
$6,819.60
|
| Rate for Payer: Devoted Health Medicare |
$3,864.44
|
| 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 |
$3,523.46
|
| 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 |
$3,523.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,229.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,796.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,523.46
|
| Rate for Payer: MDX Hawaii PPO |
$11,025.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,523.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,523.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,819.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,523.46
|
| 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
|
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-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 |
$2.48
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| 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 |
$2.72
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| 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 |
$2.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| 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 |
$2.48
|
| Rate for Payer: Humana Medicare |
$2.79
|
| 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 |
$2.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
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 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 |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| 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 |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
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 |
$285.51 |
| Max. Negotiated Rate |
$893.37 |
| Rate for Payer: AlohaCare Medicaid |
$460.50
|
| Rate for Payer: AlohaCare Medicare |
$285.51
|
| Rate for Payer: Cash Price |
$552.60
|
| Rate for Payer: Devoted Health Medicare |
$313.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$285.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$874.95
|
| Rate for Payer: Health Management Network Commercial |
$782.85
|
| Rate for Payer: Humana Medicare |
$285.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$828.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$469.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$285.51
|
| Rate for Payer: MDX Hawaii PPO |
$893.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$285.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$285.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$285.51
|
| Rate for Payer: University Health Alliance Commercial |
$671.32
|
|
