|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
IP
|
$6,985.00
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,937.25 |
| Max. Negotiated Rate |
$6,775.45 |
| Rate for Payer: Cash Price |
$4,191.00
|
| Rate for Payer: Health Management Network Commercial |
$5,937.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,286.50
|
| Rate for Payer: MDX Hawaii PPO |
$6,775.45
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]
|
Facility
|
OP
|
$6,985.00
|
|
|
Service Code
|
HCPCS J1950
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,737.10 |
| Max. Negotiated Rate |
$6,775.45 |
| Rate for Payer: AlohaCare Medicaid |
$3,492.50
|
| Rate for Payer: AlohaCare Medicare |
$5,308.60
|
| Rate for Payer: Cash Price |
$4,191.00
|
| Rate for Payer: Cash Price |
$4,191.00
|
| Rate for Payer: Devoted Health Medicare |
$5,867.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,737.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,206.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,308.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,737.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,635.75
|
| Rate for Payer: Health Management Network Commercial |
$5,937.25
|
| Rate for Payer: Humana Medicare |
$5,308.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$6,286.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3,562.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,308.60
|
| Rate for Payer: MDX Hawaii PPO |
$6,775.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,308.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,308.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,191.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,308.60
|
| Rate for Payer: University Health Alliance Commercial |
$5,091.37
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
IP
|
$8,227.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6,992.95 |
| Max. Negotiated Rate |
$7,980.19 |
| Rate for Payer: Cash Price |
$4,936.20
|
| Rate for Payer: Health Management Network Commercial |
$6,992.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,404.30
|
| Rate for Payer: MDX Hawaii PPO |
$7,980.19
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21045]
|
Facility
|
OP
|
$8,227.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$7,980.19 |
| Rate for Payer: AlohaCare Medicaid |
$4,113.50
|
| Rate for Payer: AlohaCare Medicare |
$6,252.52
|
| Rate for Payer: Cash Price |
$4,936.20
|
| Rate for Payer: Cash Price |
$4,936.20
|
| Rate for Payer: Devoted Health Medicare |
$6,910.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6,252.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,815.65
|
| Rate for Payer: Health Management Network Commercial |
$6,992.95
|
| Rate for Payer: Humana Medicare |
$6,252.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,404.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4,195.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$6,252.52
|
| Rate for Payer: MDX Hawaii PPO |
$7,980.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6,252.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$6,252.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4,936.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$6,252.52
|
| Rate for Payer: University Health Alliance Commercial |
$5,996.66
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
IP
|
$2,127.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,807.95 |
| Max. Negotiated Rate |
$2,063.19 |
| Rate for Payer: Cash Price |
$1,276.20
|
| Rate for Payer: Health Management Network Commercial |
$1,807.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,914.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,063.19
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE [33669]
|
Facility
|
OP
|
$2,127.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$2,063.19 |
| Rate for Payer: AlohaCare Medicaid |
$1,063.50
|
| Rate for Payer: AlohaCare Medicare |
$1,616.52
|
| Rate for Payer: Cash Price |
$1,276.20
|
| Rate for Payer: Cash Price |
$1,276.20
|
| Rate for Payer: Devoted Health Medicare |
$1,786.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,616.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,020.65
|
| Rate for Payer: Health Management Network Commercial |
$1,807.95
|
| Rate for Payer: Humana Medicare |
$1,616.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,914.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,084.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,616.52
|
| Rate for Payer: MDX Hawaii PPO |
$2,063.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,616.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,616.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1,276.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,616.52
|
| Rate for Payer: University Health Alliance Commercial |
$1,550.37
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [40801]
|
Facility
|
IP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,190.05 |
| Max. Negotiated Rate |
$3,640.41 |
| Rate for Payer: Cash Price |
$2,251.80
|
| Rate for Payer: Health Management Network Commercial |
$3,190.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,377.70
|
| Rate for Payer: MDX Hawaii PPO |
$3,640.41
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE [40801]
|
Facility
|
OP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$3,640.41 |
| Rate for Payer: AlohaCare Medicaid |
$1,876.50
|
| Rate for Payer: AlohaCare Medicare |
$2,852.28
|
| Rate for Payer: Cash Price |
$2,251.80
|
| Rate for Payer: Cash Price |
$2,251.80
|
| Rate for Payer: Devoted Health Medicare |
$3,152.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,852.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,565.35
|
| Rate for Payer: Health Management Network Commercial |
$3,190.05
|
| Rate for Payer: Humana Medicare |
$2,852.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,377.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,914.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,852.28
|
| Rate for Payer: MDX Hawaii PPO |
$3,640.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,852.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,852.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2,251.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,852.28
|
| Rate for Payer: University Health Alliance Commercial |
$2,735.56
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [110751]
|
Facility
|
IP
|
$15,954.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13,560.90 |
| Max. Negotiated Rate |
$15,475.38 |
| Rate for Payer: Cash Price |
$9,572.40
|
| Rate for Payer: Health Management Network Commercial |
$13,560.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,358.60
|
| Rate for Payer: MDX Hawaii PPO |
$15,475.38
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT [110751]
|
Facility
|
OP
|
$15,954.00
|
|
|
Service Code
|
HCPCS J9217
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.42 |
| Max. Negotiated Rate |
$15,475.38 |
| Rate for Payer: AlohaCare Medicaid |
$7,977.00
|
| Rate for Payer: AlohaCare Medicare |
$12,125.04
|
| Rate for Payer: Cash Price |
$9,572.40
|
| Rate for Payer: Cash Price |
$9,572.40
|
| Rate for Payer: Devoted Health Medicare |
$13,401.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$155.42
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12,125.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$155.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15,156.30
|
| Rate for Payer: Health Management Network Commercial |
$13,560.90
|
| Rate for Payer: Humana Medicare |
$12,125.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,358.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,136.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$12,125.04
|
| Rate for Payer: MDX Hawaii PPO |
$15,475.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12,125.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$12,125.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9,572.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$12,125.04
|
| Rate for Payer: University Health Alliance Commercial |
$11,628.87
|
|
|
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [24915]
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
HCPCS J7614
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
|
LEVALBUTEROL 0.63 MG/3 ML SOLUTION FOR NEBULIZATION [24915]
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
HCPCS J7614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J7614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: UnitedHealthcare Medicare |
$6.08
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$6.08
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$6.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.60
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Humana Medicare |
$6.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.08
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: University Health Alliance Commercial |
$5.83
|
|
|
LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION [24916]
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J7614
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.80 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Health Management Network Commercial |
$6.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER [43472]
|
Facility
|
IP
|
$258.00
|
|
|
Service Code
|
NDC 00591292754
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$219.30 |
| Max. Negotiated Rate |
$250.26 |
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Health Management Network Commercial |
$219.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$232.20
|
| Rate for Payer: MDX Hawaii PPO |
$250.26
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER [43472]
|
Facility
|
OP
|
$258.00
|
|
|
Service Code
|
NDC 00591292754
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.00 |
| Max. Negotiated Rate |
$250.26 |
| Rate for Payer: AlohaCare Medicaid |
$129.00
|
| Rate for Payer: AlohaCare Medicare |
$196.08
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Devoted Health Medicare |
$216.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$196.08
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$245.10
|
| Rate for Payer: Health Management Network Commercial |
$219.30
|
| Rate for Payer: Humana Medicare |
$196.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$232.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$131.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$196.08
|
| Rate for Payer: MDX Hawaii PPO |
$250.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$196.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$196.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$196.08
|
| Rate for Payer: University Health Alliance Commercial |
$188.06
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [113476]
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
|
|
LEVETIRACETAM 1,000 MG/100 ML IN SODIUM CHLORIDE(ISO-OSM) IV PIGGYBACK [113476]
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$122.22 |
| Rate for Payer: AlohaCare Medicaid |
$63.00
|
| Rate for Payer: AlohaCare Medicare |
$95.76
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Devoted Health Medicare |
$105.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.76
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$119.70
|
| Rate for Payer: Health Management Network Commercial |
$107.10
|
| Rate for Payer: Humana Medicare |
$95.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.76
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.76
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [113475]
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$75.66 |
| Rate for Payer: AlohaCare Medicaid |
$39.00
|
| Rate for Payer: AlohaCare Medicare |
$59.28
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Devoted Health Medicare |
$65.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.28
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$74.10
|
| Rate for Payer: Health Management Network Commercial |
$66.30
|
| Rate for Payer: Humana Medicare |
$59.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$59.28
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$59.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.28
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.28
|
| Rate for Payer: University Health Alliance Commercial |
$56.85
|
|
|
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: Kaiser Permanente Commercial |
$70.20
|
| 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 |
$10.50 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| 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: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
|
|
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 |
$10.50 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$15.96
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$17.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$15.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.96
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.96
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
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: Kaiser Permanente Commercial |
$18.90
|
| 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: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
|
