|
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
|
|
|
LEVOFLOXACIN 500 MG TABLET [18919]
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
NDC 00904635261
|
|
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 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$40.74 |
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$16.20
|
| 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 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 Medical Service Association Non-ABD |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$39.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$25.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$44.65
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
IP
|
$27.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.95 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
NDC 72578010092
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.35 |
| Max. Negotiated Rate |
$88.27 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Health Management Network Commercial |
$77.35
|
| Rate for Payer: MDX Hawaii PPO |
$88.27
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
NDC 00904635361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.62 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.90
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$31.62
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
| Rate for Payer: University Health Alliance Commercial |
$45.19
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
NDC 00904635361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.70 |
| Max. Negotiated Rate |
$60.14 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Health Management Network Commercial |
$52.70
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
LEVOFLOXACIN 750 MG TABLET [28964]
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
NDC 72578010092
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.41 |
| Max. Negotiated Rate |
$88.27 |
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.45
|
| Rate for Payer: Health Management Network Commercial |
$77.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.41
|
| Rate for Payer: MDX Hawaii PPO |
$88.27
|
| Rate for Payer: University Health Alliance Commercial |
$66.33
|
|
|
LEVONORGESTREL 1.5 MG TABLET [99445]
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
NDC 68180085211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.20 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
|
|
LEVONORGESTREL 1.5 MG TABLET [99445]
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
NDC 68180085211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.92 |
| Max. Negotiated Rate |
$89.24 |
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$87.40
|
| Rate for Payer: Health Management Network Commercial |
$78.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$57.96
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.92
|
| Rate for Payer: MDX Hawaii PPO |
$89.24
|
| Rate for Payer: University Health Alliance Commercial |
$67.06
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687049701
|
|
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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687049701
|
|
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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687049711
|
|
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
|
|
|
LEVOTHYROXINE 100 MCG TABLET [4423]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687049711
|
|
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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68180097001
|
|
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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687050801
|
|
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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 42292003901
|
|
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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68180097001
|
|
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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687050801
|
|
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
|
|
|
LEVOTHYROXINE 112 MCG TABLET [10404]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 42292003901
|
|
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
|
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687051901
|
|
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
|
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687051911
|
|
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
|
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687051911
|
|
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
|
|
|
LEVOTHYROXINE 125 MCG TABLET [4424]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687051901
|
|
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
|
|
|
LEVOTHYROXINE 150 MCG TABLET [4425]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68180097301
|
|
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
|
|
