|
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 |
$102.30
|
| Rate for Payer: AlohaCare Medicare |
$46.19
|
| 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 |
$50.66
|
| Rate for Payer: Devoted Health Medicare |
$112.20
|
| 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 |
$102.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.19
|
| 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 |
$46.19
|
| Rate for Payer: Humana Medicare |
$102.30
|
| 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 |
$46.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$102.30
|
| Rate for Payer: MDX Hawaii PPO |
$144.53
|
| Rate for Payer: MDX Hawaii PPO |
$320.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$102.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$102.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$198.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$89.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$102.30
|
| Rate for Payer: University Health Alliance Commercial |
$108.61
|
| Rate for Payer: University Health Alliance Commercial |
$240.54
|
|
|
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 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 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 |
$127.10
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Cash Price |
$246.00
|
| Rate for Payer: Devoted Health Medicare |
$139.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.10
|
| 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 |
$127.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$369.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$209.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.10
|
| Rate for Payer: MDX Hawaii PPO |
$397.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$127.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$246.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.10
|
| Rate for Payer: University Health Alliance Commercial |
$298.85
|
|
|
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 |
$25.73
|
| Rate for Payer: AlohaCare Medicare |
$9.92
|
| Rate for Payer: AlohaCare Medicare |
$16.12
|
| Rate for Payer: AlohaCare Medicare |
$16.43
|
| 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 |
$18.02
|
| Rate for Payer: Devoted Health Medicare |
$17.68
|
| Rate for Payer: Devoted Health Medicare |
$28.22
|
| Rate for Payer: Devoted Health Medicare |
$10.88
|
| 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 |
$9.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$25.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.43
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.12
|
| 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 |
$9.92
|
| Rate for Payer: Humana Medicare |
$16.43
|
| Rate for Payer: Humana Medicare |
$16.12
|
| Rate for Payer: Humana Medicare |
$25.73
|
| 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 |
$16.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.12
|
| 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 |
$16.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$25.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.92
|
| 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 |
$9.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.43
|
| Rate for Payer: UnitedHealthcare Medicare |
$25.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.12
|
| 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 |
$1,703.76
|
| Rate for Payer: AlohaCare Medicare |
$4,104.71
|
| 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 |
$4,501.94
|
| Rate for Payer: Devoted Health Medicare |
$1,868.64
|
| 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 |
$1,703.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,104.71
|
| 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 |
$4,104.71
|
| Rate for Payer: Humana Medicare |
$1,703.76
|
| 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 |
$4,104.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,703.76
|
| 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 |
$1,703.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,104.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,104.71
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,703.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,297.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7,944.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,104.71
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,703.76
|
| 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
|
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 |
$34.72
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Devoted Health Medicare |
$38.08
|
| 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 |
$34.72
|
| 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 |
$34.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$57.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$34.72
|
| Rate for Payer: MDX Hawaii PPO |
$108.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$34.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$34.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$67.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$34.72
|
| Rate for Payer: University Health Alliance Commercial |
$81.64
|
|
|
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 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 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 |
$84.94
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Cash Price |
$164.40
|
| Rate for Payer: Devoted Health Medicare |
$93.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.94
|
| 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 |
$84.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$139.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.94
|
| Rate for Payer: MDX Hawaii PPO |
$265.78
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.94
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.94
|
| Rate for Payer: UnitedHealthcare Medicaid |
$164.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.94
|
| 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: 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 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 |
$26.04
|
| Rate for Payer: AlohaCare Medicare |
$60.45
|
| 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 |
$66.30
|
| Rate for Payer: Devoted Health Medicare |
$28.56
|
| 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 |
$26.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.45
|
| 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 |
$60.45
|
| Rate for Payer: Humana Medicare |
$26.04
|
| 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 |
$60.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.04
|
| Rate for Payer: MDX Hawaii PPO |
$189.15
|
| Rate for Payer: MDX Hawaii PPO |
$81.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$50.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$117.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.04
|
| Rate for Payer: University Health Alliance Commercial |
$142.14
|
| Rate for Payer: University Health Alliance Commercial |
$61.23
|
|
|
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 |
$169.57
|
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Cash Price |
$328.20
|
| Rate for Payer: Devoted Health Medicare |
$185.98
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$169.57
|
| 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 |
$169.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$492.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$278.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$169.57
|
| Rate for Payer: MDX Hawaii PPO |
$530.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$169.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$169.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$328.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$169.57
|
| 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
|
|
|
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: Kaiser Permanente Commercial |
$157.50
|
| 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 |
$54.25 |
| Max. Negotiated Rate |
$169.75 |
| Rate for Payer: AlohaCare Medicaid |
$87.50
|
| Rate for Payer: AlohaCare Medicare |
$54.25
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Devoted Health Medicare |
$59.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$122.50
|
| Rate for Payer: Health Management Network Commercial |
$148.75
|
| Rate for Payer: Humana Medicare |
$54.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$157.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.25
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.25
|
| Rate for Payer: MDX Hawaii PPO |
$169.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.25
|
| 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 |
$939.60
|
| Rate for Payer: Cash Price |
$4,698.00
|
| Rate for Payer: Health Management Network Commercial |
$1,331.10
|
| Rate for Payer: Health Management Network Commercial |
$6,655.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,409.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,047.00
|
| Rate for Payer: MDX Hawaii PPO |
$7,595.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,519.02
|
|
|
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 |
$783.00
|
| Rate for Payer: AlohaCare Medicaid |
$3,915.00
|
| Rate for Payer: AlohaCare Medicare |
$2,427.30
|
| Rate for Payer: AlohaCare Medicare |
$485.46
|
| 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: Cash Price |
$939.60
|
| Rate for Payer: Devoted Health Medicare |
$532.44
|
| Rate for Payer: Devoted Health Medicare |
$2,662.20
|
| 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 |
$2,427.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$485.46
|
| 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 |
$485.46
|
| Rate for Payer: Humana Medicare |
$2,427.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,409.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,047.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,993.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$798.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$485.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,427.30
|
| 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 |
$2,427.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$485.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$485.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,427.30
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,698.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$939.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$485.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,427.30
|
| 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
|
$50,817.09
|
|
|
Service Code
|
MSDRG 062
|
| Min. Negotiated Rate |
$50,817.09 |
| Max. Negotiated Rate |
$50,817.09 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,817.09
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC
|
Facility
|
IP
|
$50,817.09
|
|
|
Service Code
|
MSDRG 061
|
| Min. Negotiated Rate |
$50,817.09 |
| Max. Negotiated Rate |
$50,817.09 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,817.09
|
|
|
ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC
|
Facility
|
IP
|
$50,817.09
|
|
|
Service Code
|
MSDRG 063
|
| Min. Negotiated Rate |
$50,817.09 |
| Max. Negotiated Rate |
$50,817.09 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$50,817.09
|
|
|
ISOFLEX PACING LEAD 1948-58CM
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS C1898
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$465.00 |
| Max. Negotiated Rate |
$1,455.00 |
| Rate for Payer: AlohaCare Medicaid |
$750.00
|
| Rate for Payer: AlohaCare Medicare |
$465.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Devoted Health Medicare |
$510.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$465.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,050.00
|
| Rate for Payer: Health Management Network Commercial |
$1,275.00
|
| Rate for Payer: Humana Medicare |
$465.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$765.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$465.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$465.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$465.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$465.00
|
| 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: Kaiser Permanente Commercial |
$1,350.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,455.00
|
| Rate for Payer: University Health Alliance Commercial |
$840.00
|
|
