|
OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$355.00
|
|
|
Service Code
|
HCPCS 99214
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$63.45 |
| Max. Negotiated Rate |
$301.75 |
| Rate for Payer: AlohaCare Medicaid |
$98.27
|
| Rate for Payer: AlohaCare Medicare |
$84.69
|
| Rate for Payer: Cash Price |
$230.75
|
| Rate for Payer: Cash Price |
$230.75
|
| Rate for Payer: Cash Price |
$230.75
|
| Rate for Payer: Devoted Health Medicare |
$84.69
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$63.45
|
| Rate for Payer: Health Management Network Commercial |
$301.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$101.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.27
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 99212
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$29.59 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$35.51
|
| Rate for Payer: AlohaCare Medicare |
$31.00
|
| Rate for Payer: Cash Price |
$48.75
|
| Rate for Payer: Cash Price |
$48.75
|
| Rate for Payer: Cash Price |
$48.75
|
| Rate for Payer: Devoted Health Medicare |
$31.00
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.59
|
| Rate for Payer: Health Management Network Commercial |
$63.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$29.00
|
|
|
Service Code
|
HCPCS 99211
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$8.86
|
| Rate for Payer: AlohaCare Medicare |
$7.72
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Cash Price |
$18.85
|
| Rate for Payer: Devoted Health Medicare |
$7.72
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.23
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$643.00
|
|
|
Service Code
|
HCPCS 99205
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$135.52 |
| Max. Negotiated Rate |
$546.55 |
| Rate for Payer: AlohaCare Medicaid |
$182.72
|
| Rate for Payer: AlohaCare Medicare |
$159.56
|
| Rate for Payer: Cash Price |
$417.95
|
| Rate for Payer: Cash Price |
$417.95
|
| Rate for Payer: Cash Price |
$417.95
|
| Rate for Payer: Devoted Health Medicare |
$159.56
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.52
|
| Rate for Payer: Health Management Network Commercial |
$546.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$191.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$182.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$159.56
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
HCPCS 99203
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$70.97 |
| Max. Negotiated Rate |
$302.60 |
| Rate for Payer: AlohaCare Medicaid |
$82.26
|
| Rate for Payer: AlohaCare Medicare |
$70.97
|
| Rate for Payer: Cash Price |
$231.40
|
| Rate for Payer: Cash Price |
$231.40
|
| Rate for Payer: Cash Price |
$231.40
|
| Rate for Payer: Devoted Health Medicare |
$70.97
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$77.24
|
| Rate for Payer: Health Management Network Commercial |
$302.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$471.00
|
|
|
Service Code
|
HCPCS 99204
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$112.99 |
| Max. Negotiated Rate |
$400.35 |
| Rate for Payer: AlohaCare Medicaid |
$134.25
|
| Rate for Payer: AlohaCare Medicare |
$116.55
|
| Rate for Payer: Cash Price |
$306.15
|
| Rate for Payer: Cash Price |
$306.15
|
| Rate for Payer: Cash Price |
$306.15
|
| Rate for Payer: Devoted Health Medicare |
$116.55
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.99
|
| Rate for Payer: Health Management Network Commercial |
$400.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$139.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$134.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$116.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$271.00
|
|
|
Service Code
|
HCPCS 99202
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$41.15 |
| Max. Negotiated Rate |
$290.48 |
| Rate for Payer: AlohaCare Medicaid |
$47.75
|
| Rate for Payer: AlohaCare Medicare |
$41.15
|
| Rate for Payer: Cash Price |
$176.15
|
| Rate for Payer: Cash Price |
$176.15
|
| Rate for Payer: Cash Price |
$176.15
|
| Rate for Payer: Devoted Health Medicare |
$41.15
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$290.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$152.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.13
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.98
|
| Rate for Payer: Health Management Network Commercial |
$230.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.13
|
| Rate for Payer: Kaiser Permanente Medicaid |
$290.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$152.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.13
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$41.15
|
| Rate for Payer: UnitedHealthcare Medicaid |
$290.48
|
| Rate for Payer: UnitedHealthcare Medicare |
$152.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.13
|
|
|
ofloxacin ophthalmic 0.3% Sol [KMC]
|
Facility
|
OP
|
$56.28
|
|
|
Service Code
|
NDC 72603019201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.64 |
| Max. Negotiated Rate |
$54.59 |
| Rate for Payer: AlohaCare Medicaid |
$28.14
|
| Rate for Payer: AlohaCare Medicare |
$23.64
|
| Rate for Payer: Cash Price |
$36.58
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$51.78
|
| Rate for Payer: Devoted Health Medicare |
$23.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.47
|
| Rate for Payer: Health Management Network Commercial |
$47.84
|
| Rate for Payer: Humana Medicare |
$23.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.64
|
| Rate for Payer: MDX Hawaii PPO |
$54.59
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.77
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.64
|
| Rate for Payer: University Health Alliance Commercial |
$41.02
|
|
|
ofloxacin ophthalmic 0.3% Sol [KMC]
|
Facility
|
IP
|
$56.28
|
|
|
Service Code
|
NDC 72603019201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.84 |
| Max. Negotiated Rate |
$54.59 |
| Rate for Payer: Cash Price |
$36.58
|
| Rate for Payer: Health Management Network Commercial |
$47.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.65
|
| Rate for Payer: MDX Hawaii PPO |
$54.59
|
|
|
ofloxacin otic (EAR) drops 0.3% Sol [KMC]
|
Facility
|
OP
|
$125.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.87 |
| Max. Negotiated Rate |
$122.09 |
| Rate for Payer: AlohaCare Medicaid |
$62.94
|
| Rate for Payer: AlohaCare Medicare |
$52.87
|
| Rate for Payer: Cash Price |
$81.82
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$115.80
|
| Rate for Payer: Devoted Health Medicare |
$52.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.58
|
| Rate for Payer: Health Management Network Commercial |
$106.99
|
| Rate for Payer: Humana Medicare |
$52.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.19
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.87
|
| Rate for Payer: MDX Hawaii PPO |
$122.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.87
|
| Rate for Payer: University Health Alliance Commercial |
$91.75
|
|
|
ofloxacin otic (EAR) drops 0.3% Sol [KMC]
|
Facility
|
IP
|
$125.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.99 |
| Max. Negotiated Rate |
$122.09 |
| Rate for Payer: Cash Price |
$81.82
|
| Rate for Payer: Health Management Network Commercial |
$106.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.28
|
| Rate for Payer: MDX Hawaii PPO |
$122.09
|
|
|
OLANZapine 10 mg REC vial [KMC]
|
Facility
|
IP
|
$170.12
|
|
|
Service Code
|
NDC 55150030801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$144.60 |
| Max. Negotiated Rate |
$165.02 |
| Rate for Payer: Cash Price |
$110.58
|
| Rate for Payer: Health Management Network Commercial |
$144.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.11
|
| Rate for Payer: MDX Hawaii PPO |
$165.02
|
|
|
OLANZapine 10 mg REC vial [KMC]
|
Facility
|
OP
|
$170.12
|
|
|
Service Code
|
NDC 55150030801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.45 |
| Max. Negotiated Rate |
$165.02 |
| Rate for Payer: AlohaCare Medicaid |
$85.06
|
| Rate for Payer: AlohaCare Medicare |
$71.45
|
| Rate for Payer: Cash Price |
$110.58
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$156.51
|
| Rate for Payer: Devoted Health Medicare |
$71.45
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$71.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$161.61
|
| Rate for Payer: Health Management Network Commercial |
$144.60
|
| Rate for Payer: Humana Medicare |
$71.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$153.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$71.45
|
| Rate for Payer: MDX Hawaii PPO |
$165.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$71.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$102.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$71.45
|
| Rate for Payer: University Health Alliance Commercial |
$124.00
|
|
|
OLANZapine 10 mg Tab [KMC]
|
Facility
|
IP
|
$78.27
|
|
|
Service Code
|
NDC 72603015701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$66.53 |
| Max. Negotiated Rate |
$75.92 |
| Rate for Payer: Cash Price |
$50.88
|
| Rate for Payer: Health Management Network Commercial |
$66.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.44
|
| Rate for Payer: MDX Hawaii PPO |
$75.92
|
|
|
OLANZapine 10 mg Tab [KMC]
|
Facility
|
OP
|
$78.27
|
|
|
Service Code
|
NDC 72603015701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.87 |
| Max. Negotiated Rate |
$75.92 |
| Rate for Payer: AlohaCare Medicaid |
$39.13
|
| Rate for Payer: AlohaCare Medicare |
$32.87
|
| Rate for Payer: Cash Price |
$50.88
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$72.01
|
| Rate for Payer: Devoted Health Medicare |
$32.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.36
|
| Rate for Payer: Health Management Network Commercial |
$66.53
|
| Rate for Payer: Humana Medicare |
$32.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.87
|
| Rate for Payer: MDX Hawaii PPO |
$75.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.87
|
| Rate for Payer: University Health Alliance Commercial |
$57.05
|
|
|
OLANZapine 2.5 mg Tab [KMC]
|
Facility
|
IP
|
$43.19
|
|
|
Service Code
|
NDC 72603015401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.71 |
| Max. Negotiated Rate |
$41.89 |
| Rate for Payer: Cash Price |
$28.07
|
| Rate for Payer: Health Management Network Commercial |
$36.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.87
|
| Rate for Payer: MDX Hawaii PPO |
$41.89
|
|
|
OLANZapine 2.5 mg Tab [KMC]
|
Facility
|
OP
|
$43.19
|
|
|
Service Code
|
NDC 72603015401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$41.89 |
| Rate for Payer: AlohaCare Medicaid |
$21.59
|
| Rate for Payer: AlohaCare Medicare |
$18.14
|
| Rate for Payer: Cash Price |
$28.07
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$39.73
|
| Rate for Payer: Devoted Health Medicare |
$18.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$18.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.03
|
| Rate for Payer: Health Management Network Commercial |
$36.71
|
| Rate for Payer: Humana Medicare |
$18.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$18.14
|
| Rate for Payer: MDX Hawaii PPO |
$41.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$18.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$18.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$18.14
|
| Rate for Payer: University Health Alliance Commercial |
$31.48
|
|
|
olopatadine 0.1% eye drops [KMC]
|
Facility
|
OP
|
$8.59
|
|
|
Service Code
|
NDC 43598076507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$8.33 |
| Rate for Payer: AlohaCare Medicaid |
$4.29
|
| Rate for Payer: AlohaCare Medicare |
$3.61
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$7.90
|
| Rate for Payer: Devoted Health Medicare |
$3.61
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.16
|
| Rate for Payer: Health Management Network Commercial |
$7.30
|
| Rate for Payer: Humana Medicare |
$3.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.61
|
| Rate for Payer: MDX Hawaii PPO |
$8.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.61
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.61
|
| Rate for Payer: University Health Alliance Commercial |
$6.26
|
|
|
olopatadine 0.1% eye drops [KMC]
|
Facility
|
IP
|
$8.59
|
|
|
Service Code
|
NDC 43598076507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.30 |
| Max. Negotiated Rate |
$8.33 |
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Health Management Network Commercial |
$7.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.73
|
| Rate for Payer: MDX Hawaii PPO |
$8.33
|
|
|
olopatadine 0.2% eye drops [KMC]
|
Facility
|
OP
|
$19.10
|
|
|
Service Code
|
NDC 43598076402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$18.53 |
| Rate for Payer: AlohaCare Medicaid |
$9.55
|
| Rate for Payer: AlohaCare Medicare |
$8.02
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$17.57
|
| Rate for Payer: Devoted Health Medicare |
$8.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.14
|
| Rate for Payer: Health Management Network Commercial |
$16.23
|
| Rate for Payer: Humana Medicare |
$8.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.02
|
| Rate for Payer: MDX Hawaii PPO |
$18.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.02
|
| Rate for Payer: University Health Alliance Commercial |
$13.92
|
|
|
olopatadine 0.2% eye drops [KMC]
|
Facility
|
IP
|
$19.10
|
|
|
Service Code
|
NDC 43598076402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.23 |
| Max. Negotiated Rate |
$18.53 |
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: Health Management Network Commercial |
$16.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.19
|
| Rate for Payer: MDX Hawaii PPO |
$18.53
|
|
|
omadacycline 150 mg Tab
|
Facility
|
IP
|
$1,301.04
|
|
|
Service Code
|
NDC 71715000221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,105.88 |
| Max. Negotiated Rate |
$1,262.01 |
| Rate for Payer: Cash Price |
$845.68
|
| Rate for Payer: Health Management Network Commercial |
$1,105.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,170.94
|
| Rate for Payer: MDX Hawaii PPO |
$1,262.01
|
|
|
omadacycline 150 mg Tab
|
Facility
|
OP
|
$1,301.04
|
|
|
Service Code
|
NDC 71715000221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$546.44 |
| Max. Negotiated Rate |
$1,262.01 |
| Rate for Payer: AlohaCare Medicaid |
$650.52
|
| Rate for Payer: AlohaCare Medicare |
$546.44
|
| Rate for Payer: Cash Price |
$845.68
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,196.96
|
| Rate for Payer: Devoted Health Medicare |
$546.44
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$546.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,235.99
|
| Rate for Payer: Health Management Network Commercial |
$1,105.88
|
| Rate for Payer: Humana Medicare |
$546.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,170.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$663.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$546.44
|
| Rate for Payer: MDX Hawaii PPO |
$1,262.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$546.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$546.44
|
| Rate for Payer: UnitedHealthcare Medicaid |
$780.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$546.44
|
| Rate for Payer: University Health Alliance Commercial |
$948.33
|
|
|
omalizumab 150 mg/mL Soln [KMC]
|
Facility
|
OP
|
$5,861.52
|
|
|
Service Code
|
HCPCS J2357
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.56 |
| Max. Negotiated Rate |
$5,685.67 |
| Rate for Payer: AlohaCare Medicaid |
$2,930.76
|
| Rate for Payer: AlohaCare Medicare |
$2,461.84
|
| Rate for Payer: Cash Price |
$3,809.99
|
| Rate for Payer: Cash Price |
$3,809.99
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$5,392.60
|
| Rate for Payer: Devoted Health Medicare |
$2,461.84
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$40.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$52.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,461.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,568.44
|
| Rate for Payer: Health Management Network Commercial |
$4,982.29
|
| Rate for Payer: Humana Medicare |
$2,461.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,275.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,989.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,461.84
|
| Rate for Payer: MDX Hawaii PPO |
$5,685.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,461.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,461.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$3,516.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,461.84
|
| Rate for Payer: University Health Alliance Commercial |
$4,272.46
|
|
|
omalizumab 150 mg/mL Soln [KMC]
|
Facility
|
IP
|
$5,861.52
|
|
|
Service Code
|
HCPCS J2357
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,982.29 |
| Max. Negotiated Rate |
$5,685.67 |
| Rate for Payer: Cash Price |
$3,809.99
|
| Rate for Payer: Health Management Network Commercial |
$4,982.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,275.37
|
| Rate for Payer: MDX Hawaii PPO |
$5,685.67
|
|
