|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00093970101
|
|
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
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51862085501
|
|
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
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00093970101
|
|
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
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687066111
|
|
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
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687066101
|
|
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
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687066101
|
|
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
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [9407]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 60687066111
|
|
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
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687083611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 60687083601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687083611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 60687083601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [126194]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68001017100
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [126194]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 50228046001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [126194]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 50228046001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [126194]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 62756046188
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [126194]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 62756046188
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [126194]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68001017100
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084028201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084028211
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 68084028201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.70
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.06
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
| Rate for Payer: University Health Alliance Commercial |
$4.37
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 68084028211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Health Management Network Commercial |
$5.10
|
| Rate for Payer: MDX Hawaii PPO |
$5.82
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 50228046101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [26371]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 50228046101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
CARBON FBR ROD 8.0X160 395.779
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$374.85 |
| Max. Negotiated Rate |
$712.95 |
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$698.25
|
| Rate for Payer: Health Management Network Commercial |
$624.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$463.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$374.85
|
| Rate for Payer: MDX Hawaii PPO |
$712.95
|
| Rate for Payer: University Health Alliance Commercial |
$535.74
|
|
|
CARBON FBR ROD 8.0X160 395.779
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$624.75 |
| Max. Negotiated Rate |
$712.95 |
| Rate for Payer: Cash Price |
$441.00
|
| Rate for Payer: Health Management Network Commercial |
$624.75
|
| Rate for Payer: MDX Hawaii PPO |
$712.95
|
|
