|
SIMPLIDERM SD.090.1020ELP
|
Facility
|
OP
|
$8,247.00
|
|
|
Service Code
|
HCPCS C1763
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,205.97 |
| Max. Negotiated Rate |
$7,999.59 |
| Rate for Payer: Cash Price |
$4,948.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,772.90
|
| Rate for Payer: Health Management Network Commercial |
$7,009.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,195.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,205.97
|
| Rate for Payer: MDX Hawaii PPO |
$7,999.59
|
| Rate for Payer: University Health Alliance Commercial |
$4,618.32
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT
|
Facility
|
IP
|
$713,444.67
|
|
|
Service Code
|
MSDRG 008
|
| Min. Negotiated Rate |
$10,400.00 |
| Max. Negotiated Rate |
$713,444.67 |
| Rate for Payer: AlohaCare Medicare |
$63,748.15
|
| Rate for Payer: Devoted Health Medicare |
$70,122.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$713,444.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$63,748.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$96,679.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$63,748.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$63,748.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$63,748.15
|
| Rate for Payer: University Health Alliance Commercial |
$10,400.00
|
|
|
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS
|
Facility
|
IP
|
$114,319.20
|
|
|
Service Code
|
MSDRG 019
|
| Min. Negotiated Rate |
$81,150.76 |
| Max. Negotiated Rate |
$114,319.20 |
| Rate for Payer: AlohaCare Medicare |
$81,150.76
|
| Rate for Payer: Devoted Health Medicare |
$89,265.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81,150.76
|
| Rate for Payer: Humana Medicare |
$81,150.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$114,319.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$81,150.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$81,150.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$81,150.76
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
HCPCS J2805
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$209.10 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
|
|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
HCPCS J2805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.46 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$135.97
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$135.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$233.70
|
| Rate for Payer: Health Management Network Commercial |
$209.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$125.46
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$147.60
|
| Rate for Payer: University Health Alliance Commercial |
$179.31
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$118,345.28
|
|
|
Service Code
|
MSDRG 402
|
| Min. Negotiated Rate |
$45,730.20 |
| Max. Negotiated Rate |
$118,345.28 |
| Rate for Payer: AlohaCare Medicare |
$45,730.20
|
| Rate for Payer: Devoted Health Medicare |
$50,303.22
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$118,345.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45,730.20
|
| Rate for Payer: Humana Medicare |
$45,730.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$69,353.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$45,730.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$45,730.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$45,730.20
|
|
|
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE
|
Facility
|
IP
|
$91,935.60
|
|
|
Service Code
|
MSDRG 450
|
| Min. Negotiated Rate |
$60,620.24 |
| Max. Negotiated Rate |
$91,935.60 |
| Rate for Payer: AlohaCare Medicare |
$60,620.24
|
| Rate for Payer: Devoted Health Medicare |
$66,682.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60,620.24
|
| Rate for Payer: Humana Medicare |
$60,620.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$91,935.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$60,620.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$60,620.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$60,620.24
|
|
|
SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC
|
Facility
|
IP
|
$55,724.40
|
|
|
Service Code
|
MSDRG 451
|
| Min. Negotiated Rate |
$36,743.40 |
| Max. Negotiated Rate |
$55,724.40 |
| Rate for Payer: AlohaCare Medicare |
$36,743.40
|
| Rate for Payer: Devoted Health Medicare |
$40,417.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36,743.40
|
| Rate for Payer: Humana Medicare |
$36,743.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$55,724.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$36,743.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$36,743.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$36,743.40
|
|
|
SINGLE LOOP SNARE RETRIEV KIT
|
Facility
|
IP
|
$998.00
|
|
|
Service Code
|
HCPCS C1773
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$848.30 |
| Max. Negotiated Rate |
$968.06 |
| Rate for Payer: Cash Price |
$598.80
|
| Rate for Payer: Health Management Network Commercial |
$848.30
|
| Rate for Payer: MDX Hawaii PPO |
$968.06
|
|
|
SINGLE LOOP SNARE RETRIEV KIT
|
Facility
|
OP
|
$998.00
|
|
|
Service Code
|
HCPCS C1773
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$508.98 |
| Max. Negotiated Rate |
$968.06 |
| Rate for Payer: Cash Price |
$598.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$948.10
|
| Rate for Payer: Health Management Network Commercial |
$848.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$628.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$508.98
|
| Rate for Payer: MDX Hawaii PPO |
$968.06
|
| Rate for Payer: University Health Alliance Commercial |
$727.44
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$36,487.20
|
|
|
Service Code
|
MSDRG 135
|
| Min. Negotiated Rate |
$24,682.15 |
| Max. Negotiated Rate |
$36,487.20 |
| Rate for Payer: AlohaCare Medicare |
$24,682.15
|
| Rate for Payer: Devoted Health Medicare |
$27,150.37
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26,498.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24,682.15
|
| Rate for Payer: Humana Medicare |
$24,682.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$36,487.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$24,682.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$24,682.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$24,682.15
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$26,498.47
|
|
|
Service Code
|
MSDRG 136
|
| Min. Negotiated Rate |
$11,548.29 |
| Max. Negotiated Rate |
$26,498.47 |
| Rate for Payer: AlohaCare Medicare |
$11,548.29
|
| Rate for Payer: Devoted Health Medicare |
$12,703.12
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26,498.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,548.29
|
| Rate for Payer: Humana Medicare |
$11,548.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$17,513.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,548.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,548.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,548.29
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J7520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
SIROLIMUS 0.5 MG TABLET [104764]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J7520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006027728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006027728
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006027701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006027701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006022128
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006022131
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006022101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006022101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006022128
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 25 MG TABLET [77615]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006022131
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.83 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006011201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.05 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
