|
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
|
|
|
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 |
$2.48
|
| Rate for Payer: AlohaCare Medicare |
$6.51
|
| 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 |
$7.14
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| 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 |
$2.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.51
|
| 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 |
$6.51
|
| Rate for Payer: Humana Medicare |
$2.48
|
| 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 |
$6.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| 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: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$2.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Devoted Health Medicare |
$2.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.48
|
| 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 |
$2.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.48
|
| Rate for Payer: MDX Hawaii PPO |
$7.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.48
|
| 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 |
$79.98 |
| Max. Negotiated Rate |
$250.26 |
| Rate for Payer: AlohaCare Medicaid |
$129.00
|
| Rate for Payer: AlohaCare Medicare |
$79.98
|
| Rate for Payer: Cash Price |
$154.80
|
| Rate for Payer: Devoted Health Medicare |
$87.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$79.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$245.10
|
| Rate for Payer: Health Management Network Commercial |
$219.30
|
| Rate for Payer: Humana Medicare |
$79.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$232.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$131.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$79.98
|
| Rate for Payer: MDX Hawaii PPO |
$250.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$79.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$79.98
|
| Rate for Payer: UnitedHealthcare Medicare |
$79.98
|
| 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 |
$39.06
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Devoted Health Medicare |
$42.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.06
|
| 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 |
$39.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$113.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$64.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.06
|
| Rate for Payer: MDX Hawaii PPO |
$122.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$75.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.06
|
| Rate for Payer: University Health Alliance Commercial |
$91.84
|
|
|
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/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 |
$24.18
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Cash Price |
$46.80
|
| Rate for Payer: Devoted Health Medicare |
$26.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.18
|
| 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 |
$24.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$39.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.18
|
| Rate for Payer: MDX Hawaii PPO |
$75.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$46.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.18
|
| Rate for Payer: University Health Alliance Commercial |
$56.85
|
|
|
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 |
$6.82 |
| Max. Negotiated Rate |
$21.34 |
| Rate for Payer: AlohaCare Medicaid |
$11.00
|
| Rate for Payer: AlohaCare Medicare |
$6.82
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Devoted Health Medicare |
$7.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.90
|
| Rate for Payer: Health Management Network Commercial |
$18.70
|
| Rate for Payer: Humana Medicare |
$6.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.82
|
| Rate for Payer: MDX Hawaii PPO |
$21.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.82
|
| Rate for Payer: University Health Alliance Commercial |
$16.04
|
|
|
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
|
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
|
|
|
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
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 60687024967
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$6.51
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$6.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.51
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.51
|
| Rate for Payer: University Health Alliance Commercial |
$15.31
|
|
|
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 |
$6.51 |
| Max. Negotiated Rate |
$20.37 |
| Rate for Payer: AlohaCare Medicaid |
$10.50
|
| Rate for Payer: AlohaCare Medicare |
$6.51
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Devoted Health Medicare |
$7.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.95
|
| Rate for Payer: Health Management Network Commercial |
$17.85
|
| Rate for Payer: Humana Medicare |
$6.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.51
|
| Rate for Payer: MDX Hawaii PPO |
$20.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.51
|
| 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: 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/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 |
$5.27
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| 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 |
$5.10
|
| Rate for Payer: Devoted Health Medicare |
$5.78
|
| 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 |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.27
|
| 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 |
$4.65
|
| Rate for Payer: Humana Medicare |
$5.27
|
| 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 |
$5.27
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$16.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.27
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$12.39
|
|
|
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 60687065701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| 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
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 60687065711
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
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 |
$43.40
|
| Rate for Payer: AlohaCare Medicare |
$39.99
|
| 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 |
$43.86
|
| Rate for Payer: Devoted Health Medicare |
$47.60
|
| 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 |
$43.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.99
|
| 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 |
$39.99
|
| Rate for Payer: Humana Medicare |
$43.40
|
| 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 |
$39.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$125.13
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$84.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$77.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.40
|
| Rate for Payer: University Health Alliance Commercial |
$94.03
|
| Rate for Payer: University Health Alliance Commercial |
$102.05
|
|
|
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
|
|
