|
SINCALIDE 5 MCG SOLUTION FOR INJECTION [11368]
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
HCPCS J2805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.26 |
| Max. Negotiated Rate |
$238.62 |
| Rate for Payer: AlohaCare Medicaid |
$123.00
|
| Rate for Payer: AlohaCare Medicare |
$76.26
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Cash Price |
$147.60
|
| Rate for Payer: Devoted Health Medicare |
$83.64
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$135.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$76.26
|
| 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: Humana Medicare |
$76.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$221.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$125.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$76.26
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
| Rate for Payer: Ohana Health Plan Medicaid |
$76.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$76.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$147.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$76.26
|
| Rate for Payer: University Health Alliance Commercial |
$179.31
|
|
|
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: Kaiser Permanente Commercial |
$221.40
|
| Rate for Payer: MDX Hawaii PPO |
$238.62
|
|
|
SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL
|
Facility
|
IP
|
$115,594.65
|
|
|
Service Code
|
MSDRG 402
|
| Min. Negotiated Rate |
$115,594.65 |
| Max. Negotiated Rate |
$115,594.65 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$115,594.65
|
|
|
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: Kaiser Permanente Commercial |
$898.20
|
| 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 |
$309.38 |
| Max. Negotiated Rate |
$968.06 |
| Rate for Payer: AlohaCare Medicaid |
$499.00
|
| Rate for Payer: AlohaCare Medicare |
$309.38
|
| Rate for Payer: Cash Price |
$598.80
|
| Rate for Payer: Devoted Health Medicare |
$339.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$309.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$948.10
|
| Rate for Payer: Health Management Network Commercial |
$848.30
|
| Rate for Payer: Humana Medicare |
$309.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$898.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$508.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$309.38
|
| Rate for Payer: MDX Hawaii PPO |
$968.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$309.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$309.38
|
| Rate for Payer: UnitedHealthcare Medicare |
$309.38
|
| Rate for Payer: University Health Alliance Commercial |
$727.44
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$25,882.58
|
|
|
Service Code
|
MSDRG 135
|
| Min. Negotiated Rate |
$25,882.58 |
| Max. Negotiated Rate |
$25,882.58 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$25,882.58
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$25,882.58
|
|
|
Service Code
|
MSDRG 136
|
| Min. Negotiated Rate |
$25,882.58 |
| Max. Negotiated Rate |
$25,882.58 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$25,882.58
|
|
|
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: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicare |
$8.06
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Devoted Health Medicare |
$8.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.06
|
| 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: Humana Medicare |
$8.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.06
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.06
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
|
|
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: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
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: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
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: Kaiser Permanente Commercial |
$29.70
|
| 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 |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 100 MG TABLET [77617]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006027701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| 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: Kaiser Permanente Commercial |
$29.70
|
| 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: Kaiser Permanente Commercial |
$29.70
|
| 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 |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| 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: Kaiser Permanente Commercial |
$29.70
|
| 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 |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| 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 |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006011231
|
|
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: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006011228
|
|
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: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
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: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
NDC 00006011254
|
|
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: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006011201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
|
SITAGLIPTIN PHOSPHATE 50 MG TABLET [77616]
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
NDC 00006011254
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: AlohaCare Medicaid |
$16.50
|
| Rate for Payer: AlohaCare Medicare |
$10.23
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Devoted Health Medicare |
$11.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$31.35
|
| Rate for Payer: Health Management Network Commercial |
$28.05
|
| Rate for Payer: Humana Medicare |
$10.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.23
|
| Rate for Payer: MDX Hawaii PPO |
$32.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.23
|
| Rate for Payer: University Health Alliance Commercial |
$24.05
|
|
