Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [113475]

Facility

IP

$78.00

Service Code	HCPCS J1953
Hospital Revenue Code	250
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$46.80
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: MDX Hawaii PPO	$75.66

LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [36590]

Facility

OP

$21.00

Service Code	NDC 60687024940
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [36590]

Facility

IP

$22.00

Service Code	NDC 60687024977
Hospital Revenue Code	250
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: MDX Hawaii PPO	$21.34

LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [36590]

Facility

IP

$21.00

Service Code	NDC 60687024967
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$20.37

LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [36590]

Facility

IP

$21.00

Service Code	NDC 60687024940
Hospital Revenue Code	250
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: MDX Hawaii PPO	$20.37

LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [36590]

Facility

OP

$22.00

Service Code	NDC 60687024977
Hospital Revenue Code	637
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$21.34
Rate for Payer: Cash Price	$13.20
Rate for Payer: Hawaii Western Management Group Commercial	$20.90
Rate for Payer: Health Management Network Commercial	$18.70
Rate for Payer: Kaiser Permanente Commercial	$13.86
Rate for Payer: Kaiser Permanente Medicaid	$11.22
Rate for Payer: MDX Hawaii PPO	$21.34
Rate for Payer: University Health Alliance Commercial	$16.04

LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION [36590]

Facility

OP

$21.00

Service Code	NDC 60687024967
Hospital Revenue Code	637
Min. Negotiated Rate	$10.71
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Kaiser Permanente Commercial	$13.23
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: University Health Alliance Commercial	$15.31

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

IP

$15.00

Service Code	HCPCS J1953
Hospital Revenue Code	250
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: MDX Hawaii PPO	$16.49

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]

Facility

OP

$17.00

Service Code	HCPCS J1953
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$10.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.05
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$10.71
Rate for Payer: Kaiser Permanente Commercial	$9.45
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: UnitedHealthcare Medicaid	$9.00
Rate for Payer: UnitedHealthcare Medicaid	$10.20
Rate for Payer: University Health Alliance Commercial	$10.93
Rate for Payer: University Health Alliance Commercial	$12.39

LEVETIRACETAM 500 MG TABLET [26817]

Facility

OP

$3.00

Service Code	NDC 60687065711
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

LEVETIRACETAM 500 MG TABLET [26817]

Facility

OP

$3.00

Service Code	NDC 60687065701
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$1.89
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: University Health Alliance Commercial	$2.19

LEVETIRACETAM 500 MG TABLET [26817]

Facility

IP

$3.00

Service Code	NDC 60687065711
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

LEVETIRACETAM 500 MG TABLET [26817]

Facility

IP

$3.00

Service Code	NDC 60687065701
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: MDX Hawaii PPO	$2.91

LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]

Facility

OP

$140.00

Service Code	HCPCS J1955
Hospital Revenue Code	636
Min. Negotiated Rate	$24.29
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Hawaii Medical Service Association ABD	$24.29
Rate for Payer: Hawaii Medical Service Association ABD	$24.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.29
Rate for Payer: Hawaii Western Management Group Commercial	$122.55
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Commercial	$81.27
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: UnitedHealthcare Medicaid	$77.40
Rate for Payer: UnitedHealthcare Medicaid	$84.00
Rate for Payer: University Health Alliance Commercial	$102.05
Rate for Payer: University Health Alliance Commercial	$94.03

LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]

Facility

IP

$129.00

Service Code	HCPCS J1955
Hospital Revenue Code	250
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$125.13
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: MDX Hawaii PPO	$135.80

LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION [41623]

Facility

IP

$115.00

Service Code	NDC 52817083004
Hospital Revenue Code	250
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$69.00
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: MDX Hawaii PPO	$111.55

LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION [41623]

Facility

OP

$115.00

Service Code	NDC 52817083004
Hospital Revenue Code	637
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$111.55
Rate for Payer: Cash Price	$69.00
Rate for Payer: Hawaii Western Management Group Commercial	$109.25
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$72.45
Rate for Payer: Kaiser Permanente Medicaid	$58.65
Rate for Payer: MDX Hawaii PPO	$111.55
Rate for Payer: University Health Alliance Commercial	$83.82

LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]

Facility

OP

$18.00

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Hawaii Western Management Group Commercial	$17.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Commercial	$11.34
Rate for Payer: Kaiser Permanente Medicaid	$9.18
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: UnitedHealthcare Medicaid	$10.80
Rate for Payer: University Health Alliance Commercial	$13.12
Rate for Payer: University Health Alliance Commercial	$18.95

LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]

Facility

IP

$18.00

Service Code	HCPCS J1956
Hospital Revenue Code	250
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Health Management Network Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$17.46
Rate for Payer: MDX Hawaii PPO	$25.22

LEVOFLOXACIN 250 MG TABLET [18918]

Facility

IP

$43.00

Service Code	NDC 65862053650
Hospital Revenue Code	250
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: MDX Hawaii PPO	$41.71

LEVOFLOXACIN 250 MG TABLET [18918]

Facility

OP

$43.00

Service Code	NDC 65862053650
Hospital Revenue Code	637
Min. Negotiated Rate	$21.93
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$27.09
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: University Health Alliance Commercial	$31.34

LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]

Facility

IP

$25.00

Service Code	HCPCS J1956
Hospital Revenue Code	250
Min. Negotiated Rate	$21.25
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$25.22

LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]

Facility

OP

$25.00

Service Code	HCPCS J1956
Hospital Revenue Code	636
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.96
Rate for Payer: Hawaii Western Management Group Commercial	$24.70
Rate for Payer: Hawaii Western Management Group Commercial	$23.75
Rate for Payer: Health Management Network Commercial	$21.25
Rate for Payer: Health Management Network Commercial	$22.10
Rate for Payer: Kaiser Permanente Commercial	$16.38
Rate for Payer: Kaiser Permanente Commercial	$15.75
Rate for Payer: Kaiser Permanente Medicaid	$12.75
Rate for Payer: Kaiser Permanente Medicaid	$13.26
Rate for Payer: MDX Hawaii PPO	$24.25
Rate for Payer: MDX Hawaii PPO	$25.22
Rate for Payer: UnitedHealthcare Medicaid	$15.60
Rate for Payer: UnitedHealthcare Medicaid	$15.00
Rate for Payer: University Health Alliance Commercial	$18.22
Rate for Payer: University Health Alliance Commercial	$18.95

LEVOFLOXACIN 500 MG TABLET [18919]

Facility

OP

$49.00

Service Code	NDC 72578009918
Hospital Revenue Code	637
Min. Negotiated Rate	$24.99
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$29.40
Rate for Payer: Hawaii Western Management Group Commercial	$46.55
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$30.87
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: University Health Alliance Commercial	$35.72

LEVOFLOXACIN 500 MG TABLET [18919]

Facility

OP

$43.00

Service Code	NDC 00904635261
Hospital Revenue Code	637
Min. Negotiated Rate	$21.93
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Hawaii Western Management Group Commercial	$40.85
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Kaiser Permanente Commercial	$27.09
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: University Health Alliance Commercial	$31.34

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