|
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 |
$11.00 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$16.72
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$18.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$16.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.72
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.72
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicaid |
$8.50
|
| Rate for Payer: AlohaCare Medicare |
$12.92
|
| Rate for Payer: AlohaCare Medicare |
$11.40
|
| 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: Devoted Health Medicare |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$14.28
|
| 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 Medicare |
$11.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.92
|
| 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 |
$14.45
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$11.40
|
| Rate for Payer: Humana Medicare |
$12.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.40
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.92
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
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: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687065701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| 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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687065711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
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 |
$109.65
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS J1955
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.29 |
| Max. Negotiated Rate |
$125.13 |
| Rate for Payer: AlohaCare Medicaid |
$64.50
|
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$106.40
|
| Rate for Payer: AlohaCare Medicare |
$98.04
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Devoted Health Medicare |
$108.36
|
| Rate for Payer: Devoted Health Medicare |
$117.60
|
| 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 Medicare |
$106.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$98.04
|
| 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: Humana Medicare |
$98.04
|
| Rate for Payer: Humana Medicare |
$106.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$116.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.79
|
| Rate for Payer: Kaiser Permanente Medicare |
$98.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$106.40
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$98.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$98.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$106.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$98.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$106.40
|
| Rate for Payer: University Health Alliance Commercial |
$94.03
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
|
|
LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION [41623]
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
NDC 52817083004
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.50 |
| Max. Negotiated Rate |
$111.55 |
| Rate for Payer: AlohaCare Medicaid |
$57.50
|
| Rate for Payer: AlohaCare Medicare |
$87.40
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Devoted Health Medicare |
$96.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.40
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$109.25
|
| Rate for Payer: Health Management Network Commercial |
$97.75
|
| Rate for Payer: Humana Medicare |
$87.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$58.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.40
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.40
|
| Rate for Payer: University Health Alliance Commercial |
$83.82
|
|
|
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: Kaiser Permanente Commercial |
$103.50
|
| Rate for Payer: MDX Hawaii PPO |
$111.55
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108118]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicaid |
$9.00
|
| Rate for Payer: AlohaCare Medicare |
$13.68
|
| Rate for Payer: AlohaCare Medicare |
$19.76
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Devoted Health Medicare |
$15.12
|
| Rate for Payer: Devoted Health Medicare |
$21.84
|
| 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 Medicare |
$19.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.68
|
| 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 |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Humana Medicare |
$19.76
|
| Rate for Payer: Humana Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.68
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
|
|
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: Kaiser Permanente Commercial |
$38.70
|
| 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 |
$21.50 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: AlohaCare Medicaid |
$21.50
|
| Rate for Payer: AlohaCare Medicare |
$32.68
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Devoted Health Medicare |
$36.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.85
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Humana Medicare |
$32.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.68
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.68
|
| Rate for Payer: University Health Alliance Commercial |
$31.34
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: AlohaCare Medicaid |
$13.00
|
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: AlohaCare Medicare |
$19.76
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Devoted Health Medicare |
$21.84
|
| 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 Medicare |
$19.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| 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 |
$23.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.70
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.76
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.76
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.95
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108119]
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.10 |
| Max. Negotiated Rate |
$25.22 |
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$22.10
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.40
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: MDX Hawaii PPO |
$25.22
|
|
|
LEVOFLOXACIN 500 MG TABLET [18919]
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
NDC 72578009918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.65 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
|
|
LEVOFLOXACIN 500 MG TABLET [18919]
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
NDC 72578009918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$47.53 |
| Rate for Payer: AlohaCare Medicaid |
$24.50
|
| Rate for Payer: AlohaCare Medicare |
$37.24
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Devoted Health Medicare |
$41.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.55
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Humana Medicare |
$37.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$37.24
|
| Rate for Payer: MDX Hawaii PPO |
$47.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$37.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.24
|
| 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 |
$21.50 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: AlohaCare Medicaid |
$21.50
|
| Rate for Payer: AlohaCare Medicare |
$32.68
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Devoted Health Medicare |
$36.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.85
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Humana Medicare |
$32.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.68
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.68
|
| 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: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK [108120]
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$26.19 |
| Rate for Payer: AlohaCare Medicaid |
$13.50
|
| Rate for Payer: AlohaCare Medicaid |
$23.50
|
| Rate for Payer: AlohaCare Medicaid |
$21.00
|
| Rate for Payer: AlohaCare Medicare |
$31.92
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: AlohaCare Medicare |
$35.72
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Devoted Health Medicare |
$22.68
|
| Rate for Payer: Devoted Health Medicare |
$39.48
|
| Rate for Payer: Devoted Health Medicare |
$35.28
|
| 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 Medicare |
$20.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$35.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$31.92
|
| 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 |
$39.95
|
| Rate for Payer: Health Management Network Commercial |
$22.95
|
| Rate for Payer: Health Management Network Commercial |
$35.70
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Humana Medicare |
$31.92
|
| Rate for Payer: Humana Medicare |
$35.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$24.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$37.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.42
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$31.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.72
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: MDX Hawaii PPO |
$40.74
|
| Rate for Payer: MDX Hawaii PPO |
$26.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$31.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$31.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$31.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.72
|
| Rate for Payer: University Health Alliance Commercial |
$19.68
|
| Rate for Payer: University Health Alliance Commercial |
$30.61
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
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: Kaiser Permanente Commercial |
$55.80
|
| Rate for Payer: MDX Hawaii PPO |
$60.14
|
|
|
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: Kaiser Permanente Commercial |
$81.90
|
| Rate for Payer: MDX Hawaii PPO |
$88.27
|
|
