|
SCD THIGH SLEEVE LG
|
Facility
|
OP
|
$96.00
|
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$48.96 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.20
|
| Rate for Payer: Health Management Network Commercial |
$81.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.48
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.96
|
| Rate for Payer: MDX Hawaii PPO |
$93.12
|
| Rate for Payer: University Health Alliance Commercial |
$69.97
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$13,725.67
|
|
|
Service Code
|
APR-DRG 7504
|
| Min. Negotiated Rate |
$13,725.67 |
| Max. Negotiated Rate |
$13,725.67 |
| Rate for Payer: AlohaCare Medicaid |
$13,725.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$13,725.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$13,725.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13,725.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13,725.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13,725.67
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$3,881.86
|
|
|
Service Code
|
APR-DRG 7502
|
| Min. Negotiated Rate |
$3,881.86 |
| Max. Negotiated Rate |
$3,881.86 |
| Rate for Payer: AlohaCare Medicaid |
$3,881.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,881.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,881.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,881.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,881.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,881.86
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$3,109.99
|
|
|
Service Code
|
APR-DRG 7501
|
| Min. Negotiated Rate |
$3,109.99 |
| Max. Negotiated Rate |
$3,109.99 |
| Rate for Payer: AlohaCare Medicaid |
$3,109.99
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,109.99
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,109.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,109.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,109.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,109.99
|
|
|
SCHIZOPHRENIA
|
Facility
|
IP
|
$5,839.67
|
|
|
Service Code
|
APR-DRG 7503
|
| Min. Negotiated Rate |
$5,839.67 |
| Max. Negotiated Rate |
$5,839.67 |
| Rate for Payer: AlohaCare Medicaid |
$5,839.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$5,839.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5,839.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,839.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,839.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5,839.67
|
|
|
SCISSOR ENDSIZER ES26235-3
|
Facility
|
OP
|
$2,190.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,116.90 |
| Max. Negotiated Rate |
$2,124.30 |
| Rate for Payer: Cash Price |
$1,314.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,080.50
|
| Rate for Payer: Health Management Network Commercial |
$1,861.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,379.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,116.90
|
| Rate for Payer: MDX Hawaii PPO |
$2,124.30
|
| Rate for Payer: University Health Alliance Commercial |
$1,596.29
|
|
|
SCISSOR ENDSIZER ES26235-3
|
Facility
|
IP
|
$2,190.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,861.50 |
| Max. Negotiated Rate |
$2,124.30 |
| Rate for Payer: Cash Price |
$1,314.00
|
| Rate for Payer: Health Management Network Commercial |
$1,861.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,124.30
|
|
|
SCOPE URETEROSCOPE FLEXIBLE
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS C1747
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,530.00 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,850.00
|
| Rate for Payer: Health Management Network Commercial |
$2,550.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,890.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,530.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,910.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,186.70
|
|
|
SCOPE URETEROSCOPE FLEXIBLE
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS C1747
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,550.00 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Health Management Network Commercial |
$2,550.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,910.00
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [128147]
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
NDC 50742050510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.58 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.10
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.58
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: University Health Alliance Commercial |
$42.28
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [128147]
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 50742050510
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [128147]
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 45802058001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [128147]
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
NDC 45802058046
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.58 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.10
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.58
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: University Health Alliance Commercial |
$42.28
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [128147]
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
NDC 45802058001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.58 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.10
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.54
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.58
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: University Health Alliance Commercial |
$42.28
|
|
|
SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [128147]
|
Facility
|
IP
|
$58.00
|
|
|
Service Code
|
NDC 45802058046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.30 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
|
|
SCREENING PERFORMED AND NEGATIVE
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT G9920
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,837.00 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
|
|
SCREENING PERFORMED AND POSITIVE AND PROVISION OF RECOMMENDATIONS
|
Facility
|
OP
|
$2,837.00
|
|
|
Service Code
|
CPT G9919
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,837.00 |
| Max. Negotiated Rate |
$2,837.00 |
| Rate for Payer: Kaiser Permanente Medicaid |
$2,837.00
|
|
|
SCREW 1.7MM LCK 6MM
|
Facility
|
OP
|
$664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$338.64 |
| Max. Negotiated Rate |
$644.08 |
| Rate for Payer: Cash Price |
$398.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$464.80
|
| Rate for Payer: Health Management Network Commercial |
$564.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$418.32
|
| Rate for Payer: Kaiser Permanente Medicaid |
$338.64
|
| Rate for Payer: MDX Hawaii PPO |
$644.08
|
| Rate for Payer: University Health Alliance Commercial |
$371.84
|
|
|
SCREW 1.7MM LCK 6MM
|
Facility
|
IP
|
$664.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$371.84 |
| Max. Negotiated Rate |
$644.08 |
| Rate for Payer: Cash Price |
$398.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$464.80
|
| Rate for Payer: Health Management Network Commercial |
$564.40
|
| Rate for Payer: MDX Hawaii PPO |
$644.08
|
| Rate for Payer: University Health Alliance Commercial |
$371.84
|
|
|
SCREW 1.7MM NON-LCK 10MM
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.67 |
| Max. Negotiated Rate |
$404.49 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.90
|
| Rate for Payer: Health Management Network Commercial |
$354.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$262.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.67
|
| Rate for Payer: MDX Hawaii PPO |
$404.49
|
| Rate for Payer: University Health Alliance Commercial |
$233.52
|
|
|
SCREW 1.7MM NON-LCK 10MM
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.52 |
| Max. Negotiated Rate |
$404.49 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.90
|
| Rate for Payer: Health Management Network Commercial |
$354.45
|
| Rate for Payer: MDX Hawaii PPO |
$404.49
|
| Rate for Payer: University Health Alliance Commercial |
$233.52
|
|
|
SCREW 1.7MM NON-LCK 8MM
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$212.67 |
| Max. Negotiated Rate |
$404.49 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.90
|
| Rate for Payer: Health Management Network Commercial |
$354.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$262.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.67
|
| Rate for Payer: MDX Hawaii PPO |
$404.49
|
| Rate for Payer: University Health Alliance Commercial |
$233.52
|
|
|
SCREW 1.7MM NON-LCK 8MM
|
Facility
|
IP
|
$417.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$233.52 |
| Max. Negotiated Rate |
$404.49 |
| Rate for Payer: Cash Price |
$250.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$291.90
|
| Rate for Payer: Health Management Network Commercial |
$354.45
|
| Rate for Payer: MDX Hawaii PPO |
$404.49
|
| Rate for Payer: University Health Alliance Commercial |
$233.52
|
|
|
SCREW 2.4MM LCK 40MM
|
Facility
|
IP
|
$806.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.36 |
| Max. Negotiated Rate |
$781.82 |
| Rate for Payer: Cash Price |
$483.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$564.20
|
| Rate for Payer: Health Management Network Commercial |
$685.10
|
| Rate for Payer: MDX Hawaii PPO |
$781.82
|
| Rate for Payer: University Health Alliance Commercial |
$451.36
|
|
|
SCREW 2.4MM LCK 40MM
|
Facility
|
OP
|
$806.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$411.06 |
| Max. Negotiated Rate |
$781.82 |
| Rate for Payer: Cash Price |
$483.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$564.20
|
| Rate for Payer: Health Management Network Commercial |
$685.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$507.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$411.06
|
| Rate for Payer: MDX Hawaii PPO |
$781.82
|
| Rate for Payer: University Health Alliance Commercial |
$451.36
|
|
