|
SECUR-FIT MAX 6051-0935S
|
Facility
|
IP
|
$5,780.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,236.80 |
| Max. Negotiated Rate |
$5,606.60 |
| Rate for Payer: Cash Price |
$3,468.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,046.00
|
| Rate for Payer: Health Management Network Commercial |
$4,913.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,606.60
|
| Rate for Payer: University Health Alliance Commercial |
$3,236.80
|
|
|
SEIZURE
|
Facility
|
IP
|
$2,553.66
|
|
|
Service Code
|
APR-DRG 0531
|
| Min. Negotiated Rate |
$2,553.66 |
| Max. Negotiated Rate |
$2,553.66 |
| Rate for Payer: AlohaCare Medicaid |
$2,553.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2,553.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2,553.66
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,553.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,553.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,553.66
|
|
|
SEIZURE
|
Facility
|
IP
|
$4,134.13
|
|
|
Service Code
|
APR-DRG 0533
|
| Min. Negotiated Rate |
$4,134.13 |
| Max. Negotiated Rate |
$4,134.13 |
| Rate for Payer: AlohaCare Medicaid |
$4,134.13
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4,134.13
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$4,134.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,134.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,134.13
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,134.13
|
|
|
SEIZURE
|
Facility
|
IP
|
$10,032.67
|
|
|
Service Code
|
APR-DRG 0534
|
| Min. Negotiated Rate |
$10,032.67 |
| Max. Negotiated Rate |
$10,032.67 |
| Rate for Payer: AlohaCare Medicaid |
$10,032.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$10,032.67
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$10,032.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10,032.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10,032.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10,032.67
|
|
|
SEIZURE
|
Facility
|
IP
|
$3,209.86
|
|
|
Service Code
|
APR-DRG 0532
|
| Min. Negotiated Rate |
$3,209.86 |
| Max. Negotiated Rate |
$3,209.86 |
| Rate for Payer: AlohaCare Medicaid |
$3,209.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$3,209.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$3,209.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,209.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,209.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,209.86
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$33,409.80
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$22,029.66 |
| Max. Negotiated Rate |
$33,409.80 |
| Rate for Payer: AlohaCare Medicare |
$22,029.66
|
| Rate for Payer: Devoted Health Medicare |
$24,232.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$23,271.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22,029.66
|
| Rate for Payer: Humana Medicare |
$22,029.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$33,409.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$22,029.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$22,029.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$22,029.66
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$20,092.25
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$10,266.40 |
| Max. Negotiated Rate |
$20,092.25 |
| Rate for Payer: AlohaCare Medicare |
$10,266.40
|
| Rate for Payer: Devoted Health Medicare |
$11,293.04
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20,092.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10,266.40
|
| Rate for Payer: Humana Medicare |
$10,266.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$15,569.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$10,266.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$10,266.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$10,266.40
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60505005501
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
SELEGILINE 5 MG CAPSULE [17280]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60505005501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
SELENIUM SULFIDE 2.5 % LOTION [37630]
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
NDC 45802004064
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.70 |
| Max. Negotiated Rate |
$67.90 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$66.50
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$35.70
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
| Rate for Payer: University Health Alliance Commercial |
$51.02
|
|
|
SELENIUM SULFIDE 2.5 % LOTION [37630]
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
NDC 45802004064
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$59.50 |
| Max. Negotiated Rate |
$67.90 |
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Health Management Network Commercial |
$59.50
|
| Rate for Payer: MDX Hawaii PPO |
$67.90
|
|
|
SELF-PRESSURIZING GLENOID SZ48
|
Facility
|
IP
|
$4,721.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.76 |
| Max. Negotiated Rate |
$4,579.37 |
| Rate for Payer: Cash Price |
$2,832.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,304.70
|
| Rate for Payer: Health Management Network Commercial |
$4,012.85
|
| Rate for Payer: MDX Hawaii PPO |
$4,579.37
|
| Rate for Payer: University Health Alliance Commercial |
$2,643.76
|
|
|
SELF-PRESSURIZING GLENOID SZ48
|
Facility
|
OP
|
$4,721.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,407.71 |
| Max. Negotiated Rate |
$4,579.37 |
| Rate for Payer: Cash Price |
$2,832.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,304.70
|
| Rate for Payer: Health Management Network Commercial |
$4,012.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,974.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,407.71
|
| Rate for Payer: MDX Hawaii PPO |
$4,579.37
|
| Rate for Payer: University Health Alliance Commercial |
$2,643.76
|
|
|
SEMI TENDINOSIS TENDON 453015
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,408.00 |
| Max. Negotiated Rate |
$4,171.00 |
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,010.00
|
| Rate for Payer: Health Management Network Commercial |
$3,655.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,171.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,408.00
|
|
|
SEMI TENDINOSIS TENDON 453015
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS C1762
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,193.00 |
| Max. Negotiated Rate |
$4,171.00 |
| Rate for Payer: Cash Price |
$2,580.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,010.00
|
| Rate for Payer: Health Management Network Commercial |
$3,655.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,709.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,193.00
|
| Rate for Payer: MDX Hawaii PPO |
$4,171.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,408.00
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00536124801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687062201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 60687062211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00536124801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687062201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET [24216]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 60687062211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SENNOSIDES 8.6 MG TABLET [11349]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 71399824503
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SENNOSIDES 8.6 MG TABLET [11349]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904725261
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$0.95
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.51
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
| Rate for Payer: University Health Alliance Commercial |
$0.73
|
|
|
SENNOSIDES 8.6 MG TABLET [11349]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 71399824503
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
|
SENNOSIDES 8.6 MG TABLET [11349]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904725261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.85 |
| Max. Negotiated Rate |
$0.97 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Management Network Commercial |
$0.85
|
| Rate for Payer: MDX Hawaii PPO |
$0.97
|
|
