|
levalbuterol HFA 45 mcg inhaler [HHSC]
|
Facility
|
IP
|
$385.41
|
|
|
Service Code
|
NDC 63402051001
|
| Hospital Charge Code |
2500455
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$327.60 |
| Max. Negotiated Rate |
$373.85 |
| Rate for Payer: Cash Price |
$250.52
|
| Rate for Payer: Health Management Network Commercial |
$327.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$346.87
|
| Rate for Payer: MDX Hawaii PPO |
$373.85
|
|
|
levETIRAcetam 1000 mg/100mL-0.75% NaCl premix [HHSC]
|
Facility
|
IP
|
$168.63
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
2501027
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.34 |
| Max. Negotiated Rate |
$163.57 |
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Cash Price |
$187.43
|
| Rate for Payer: Health Management Network Commercial |
$143.34
|
| Rate for Payer: Health Management Network Commercial |
$245.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.51
|
| Rate for Payer: MDX Hawaii PPO |
$279.70
|
| Rate for Payer: MDX Hawaii PPO |
$163.57
|
|
|
levETIRAcetam 1000 mg/100mL-0.75% NaCl premix [HHSC]
|
Facility
|
OP
|
$168.63
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
2501027
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$163.57 |
| Rate for Payer: UnitedHealthcare Medicare |
$144.18
|
| Rate for Payer: AlohaCare Medicaid |
$84.31
|
| Rate for Payer: AlohaCare Medicaid |
$144.18
|
| Rate for Payer: AlohaCare Medicare |
$144.18
|
| Rate for Payer: AlohaCare Medicare |
$84.31
|
| Rate for Payer: Cash Price |
$187.43
|
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Cash Price |
$109.61
|
| Rate for Payer: Cash Price |
$187.43
|
| Rate for Payer: Devoted Health Medicare |
$92.75
|
| Rate for Payer: Devoted Health Medicare |
$158.59
|
| 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 |
$144.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.31
|
| 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 |
$160.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$273.93
|
| Rate for Payer: Health Management Network Commercial |
$245.10
|
| Rate for Payer: Health Management Network Commercial |
$143.34
|
| Rate for Payer: Humana Medicare |
$84.31
|
| Rate for Payer: Humana Medicare |
$144.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$151.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$259.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$147.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$144.18
|
| Rate for Payer: MDX Hawaii PPO |
$163.57
|
| Rate for Payer: MDX Hawaii PPO |
$279.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$144.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.31
|
| Rate for Payer: Ohana Health Plan Medicare |
$144.18
|
| Rate for Payer: UnitedHealthcare Medicaid |
$173.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.31
|
| Rate for Payer: University Health Alliance Commercial |
$122.91
|
| Rate for Payer: University Health Alliance Commercial |
$210.18
|
|
|
levETIRAcetam 1500 mg/100mL-0.54% NaCl premix [HHSC]
|
Facility
|
OP
|
$350.99
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
2501143
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$340.46 |
| Rate for Payer: AlohaCare Medicaid |
$175.50
|
| Rate for Payer: AlohaCare Medicaid |
$47.09
|
| Rate for Payer: AlohaCare Medicare |
$47.09
|
| Rate for Payer: AlohaCare Medicare |
$175.50
|
| Rate for Payer: Cash Price |
$61.22
|
| Rate for Payer: Cash Price |
$228.14
|
| Rate for Payer: Cash Price |
$228.14
|
| Rate for Payer: Cash Price |
$61.22
|
| Rate for Payer: Devoted Health Medicare |
$193.04
|
| Rate for Payer: Devoted Health Medicare |
$51.80
|
| 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 |
$47.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$175.50
|
| 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 |
$333.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$89.48
|
| Rate for Payer: Health Management Network Commercial |
$80.06
|
| Rate for Payer: Health Management Network Commercial |
$298.34
|
| Rate for Payer: Humana Medicare |
$175.50
|
| Rate for Payer: Humana Medicare |
$47.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$179.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$175.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.09
|
| Rate for Payer: MDX Hawaii PPO |
$340.46
|
| Rate for Payer: MDX Hawaii PPO |
$91.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$175.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$175.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$56.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$210.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$175.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.09
|
| Rate for Payer: University Health Alliance Commercial |
$255.84
|
| Rate for Payer: University Health Alliance Commercial |
$68.66
|
|
|
levETIRAcetam 1500 mg/100mL-0.54% NaCl premix [HHSC]
|
Facility
|
IP
|
$350.99
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
2501143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$298.34 |
| Max. Negotiated Rate |
$340.46 |
| Rate for Payer: Cash Price |
$228.14
|
| Rate for Payer: Cash Price |
$61.22
|
| Rate for Payer: Health Management Network Commercial |
$298.34
|
| Rate for Payer: Health Management Network Commercial |
$80.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$315.89
|
| Rate for Payer: Kaiser Permanente Commercial |
$84.77
|
| Rate for Payer: MDX Hawaii PPO |
$91.36
|
| Rate for Payer: MDX Hawaii PPO |
$340.46
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
OP
|
$55.20
|
|
|
Service Code
|
NDC 00121479940
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.60 |
| Max. Negotiated Rate |
$53.54 |
| Rate for Payer: AlohaCare Medicaid |
$27.60
|
| Rate for Payer: AlohaCare Medicare |
$27.60
|
| Rate for Payer: Cash Price |
$35.88
|
| Rate for Payer: Devoted Health Medicare |
$30.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.44
|
| Rate for Payer: Health Management Network Commercial |
$46.92
|
| Rate for Payer: Humana Medicare |
$27.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.60
|
| Rate for Payer: MDX Hawaii PPO |
$53.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.60
|
| Rate for Payer: University Health Alliance Commercial |
$40.24
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
IP
|
$55.20
|
|
|
Service Code
|
NDC 00121479940
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.92 |
| Max. Negotiated Rate |
$53.54 |
| Rate for Payer: Cash Price |
$35.88
|
| Rate for Payer: Health Management Network Commercial |
$46.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.68
|
| Rate for Payer: MDX Hawaii PPO |
$53.54
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
IP
|
$44.29
|
|
|
Service Code
|
NDC 60687024977
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.65 |
| Max. Negotiated Rate |
$42.96 |
| Rate for Payer: Cash Price |
$28.79
|
| Rate for Payer: Health Management Network Commercial |
$37.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.86
|
| Rate for Payer: MDX Hawaii PPO |
$42.96
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
OP
|
$17.80
|
|
|
Service Code
|
NDC 68180009901
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$17.27 |
| Rate for Payer: AlohaCare Medicaid |
$8.90
|
| Rate for Payer: AlohaCare Medicare |
$8.90
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: Devoted Health Medicare |
$9.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.91
|
| Rate for Payer: Health Management Network Commercial |
$15.13
|
| Rate for Payer: Humana Medicare |
$8.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.02
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.90
|
| Rate for Payer: MDX Hawaii PPO |
$17.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.90
|
| Rate for Payer: University Health Alliance Commercial |
$12.97
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
OP
|
$43.58
|
|
|
Service Code
|
NDC 60687024967
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.79 |
| Max. Negotiated Rate |
$42.27 |
| Rate for Payer: AlohaCare Medicaid |
$21.79
|
| Rate for Payer: AlohaCare Medicare |
$21.79
|
| Rate for Payer: Cash Price |
$28.33
|
| Rate for Payer: Devoted Health Medicare |
$23.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.40
|
| Rate for Payer: Health Management Network Commercial |
$37.04
|
| Rate for Payer: Humana Medicare |
$21.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.22
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.79
|
| Rate for Payer: MDX Hawaii PPO |
$42.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.79
|
| Rate for Payer: University Health Alliance Commercial |
$31.77
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
IP
|
$43.58
|
|
|
Service Code
|
NDC 60687024967
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.04 |
| Max. Negotiated Rate |
$42.27 |
| Rate for Payer: Cash Price |
$28.33
|
| Rate for Payer: Health Management Network Commercial |
$37.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.22
|
| Rate for Payer: MDX Hawaii PPO |
$42.27
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
IP
|
$18.09
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.38 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Cash Price |
$11.76
|
| Rate for Payer: Health Management Network Commercial |
$15.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.28
|
| Rate for Payer: MDX Hawaii PPO |
$17.55
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
OP
|
$18.09
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: AlohaCare Medicaid |
$9.04
|
| Rate for Payer: AlohaCare Medicare |
$9.04
|
| Rate for Payer: Cash Price |
$11.76
|
| Rate for Payer: Devoted Health Medicare |
$9.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.19
|
| Rate for Payer: Health Management Network Commercial |
$15.38
|
| Rate for Payer: Humana Medicare |
$9.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.28
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.04
|
| Rate for Payer: MDX Hawaii PPO |
$17.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.04
|
| Rate for Payer: University Health Alliance Commercial |
$13.19
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
OP
|
$44.29
|
|
|
Service Code
|
NDC 60687024977
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.14 |
| Max. Negotiated Rate |
$42.96 |
| Rate for Payer: AlohaCare Medicaid |
$22.14
|
| Rate for Payer: AlohaCare Medicare |
$22.14
|
| Rate for Payer: Cash Price |
$28.79
|
| Rate for Payer: Devoted Health Medicare |
$24.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.08
|
| Rate for Payer: Health Management Network Commercial |
$37.65
|
| Rate for Payer: Humana Medicare |
$22.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.14
|
| Rate for Payer: MDX Hawaii PPO |
$42.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.14
|
| Rate for Payer: University Health Alliance Commercial |
$32.28
|
|
|
levETIRAcetam 500 mg/5ml UD [HHSC]
|
Facility
|
IP
|
$17.80
|
|
|
Service Code
|
NDC 68180009901
|
| Hospital Charge Code |
2500458
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.13 |
| Max. Negotiated Rate |
$17.27 |
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: Health Management Network Commercial |
$15.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.02
|
| Rate for Payer: MDX Hawaii PPO |
$17.27
|
|
|
levETIRAcetam 500 mg/5ml vial [HHSC]
|
Facility
|
IP
|
$52.63
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
2500456
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.74 |
| Max. Negotiated Rate |
$51.05 |
| Rate for Payer: Cash Price |
$34.21
|
| Rate for Payer: Cash Price |
$16.86
|
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Health Management Network Commercial |
$27.68
|
| Rate for Payer: Health Management Network Commercial |
$44.74
|
| Rate for Payer: Health Management Network Commercial |
$47.97
|
| Rate for Payer: Health Management Network Commercial |
$22.05
|
| Rate for Payer: Health Management Network Commercial |
$21.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.79
|
| Rate for Payer: MDX Hawaii PPO |
$51.05
|
| Rate for Payer: MDX Hawaii PPO |
$25.16
|
| Rate for Payer: MDX Hawaii PPO |
$25.07
|
| Rate for Payer: MDX Hawaii PPO |
$31.58
|
| Rate for Payer: MDX Hawaii PPO |
$54.74
|
|
|
levETIRAcetam 500 mg/5ml vial [HHSC]
|
Facility
|
OP
|
$32.56
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
2500456
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$31.58 |
| Rate for Payer: AlohaCare Medicaid |
$16.28
|
| Rate for Payer: AlohaCare Medicaid |
$12.97
|
| Rate for Payer: AlohaCare Medicaid |
$26.32
|
| Rate for Payer: AlohaCare Medicaid |
$28.21
|
| Rate for Payer: AlohaCare Medicaid |
$12.93
|
| Rate for Payer: AlohaCare Medicare |
$16.28
|
| Rate for Payer: AlohaCare Medicare |
$26.32
|
| Rate for Payer: AlohaCare Medicare |
$28.21
|
| Rate for Payer: AlohaCare Medicare |
$12.93
|
| Rate for Payer: AlohaCare Medicare |
$12.97
|
| Rate for Payer: Cash Price |
$16.86
|
| Rate for Payer: Cash Price |
$34.21
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cash Price |
$16.86
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Cash Price |
$36.68
|
| Rate for Payer: Cash Price |
$34.21
|
| Rate for Payer: Cash Price |
$21.16
|
| Rate for Payer: Devoted Health Medicare |
$17.91
|
| Rate for Payer: Devoted Health Medicare |
$14.22
|
| Rate for Payer: Devoted Health Medicare |
$28.95
|
| Rate for Payer: Devoted Health Medicare |
$31.04
|
| Rate for Payer: Devoted Health Medicare |
$14.27
|
| 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 ABD |
$0.05
|
| 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 |
$26.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$16.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.21
|
| 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 Medical Service Association Non-ABD |
$0.05
|
| 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 |
$30.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.64
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$50.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$53.61
|
| Rate for Payer: Health Management Network Commercial |
$27.68
|
| Rate for Payer: Health Management Network Commercial |
$22.05
|
| Rate for Payer: Health Management Network Commercial |
$21.97
|
| Rate for Payer: Health Management Network Commercial |
$47.97
|
| Rate for Payer: Health Management Network Commercial |
$44.74
|
| Rate for Payer: Humana Medicare |
$16.28
|
| Rate for Payer: Humana Medicare |
$12.93
|
| Rate for Payer: Humana Medicare |
$12.97
|
| Rate for Payer: Humana Medicare |
$26.32
|
| Rate for Payer: Humana Medicare |
$28.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$47.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$50.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$29.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.35
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.61
|
| Rate for Payer: Kaiser Permanente Medicaid |
$26.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$13.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.78
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$26.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.28
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.21
|
| Rate for Payer: MDX Hawaii PPO |
$31.58
|
| Rate for Payer: MDX Hawaii PPO |
$51.05
|
| Rate for Payer: MDX Hawaii PPO |
$25.16
|
| Rate for Payer: MDX Hawaii PPO |
$25.07
|
| Rate for Payer: MDX Hawaii PPO |
$54.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$26.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$26.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$16.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.97
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$31.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$26.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$16.28
|
| Rate for Payer: University Health Alliance Commercial |
$18.84
|
| Rate for Payer: University Health Alliance Commercial |
$23.73
|
| Rate for Payer: University Health Alliance Commercial |
$38.36
|
| Rate for Payer: University Health Alliance Commercial |
$18.91
|
| Rate for Payer: University Health Alliance Commercial |
$41.13
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 68084087001
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 68084087001
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$2.00
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Devoted Health Medicare |
$2.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$2.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.00
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.00
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$1.50
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Devoted Health Medicare |
$1.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$1.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.50
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.50
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
OP
|
$17.59
|
|
|
Service Code
|
NDC 00904605261
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: AlohaCare Medicaid |
$8.79
|
| Rate for Payer: AlohaCare Medicare |
$8.79
|
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Devoted Health Medicare |
$9.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8.79
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.71
|
| Rate for Payer: Health Management Network Commercial |
$14.95
|
| Rate for Payer: Humana Medicare |
$8.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$8.79
|
| Rate for Payer: MDX Hawaii PPO |
$17.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8.79
|
| Rate for Payer: Ohana Health Plan Medicare |
$8.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$8.79
|
| Rate for Payer: University Health Alliance Commercial |
$12.82
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
OP
|
$19.54
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$18.95 |
| Rate for Payer: AlohaCare Medicaid |
$9.77
|
| Rate for Payer: AlohaCare Medicare |
$9.77
|
| Rate for Payer: Cash Price |
$12.70
|
| Rate for Payer: Devoted Health Medicare |
$10.75
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.56
|
| Rate for Payer: Health Management Network Commercial |
$16.61
|
| Rate for Payer: Humana Medicare |
$9.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.77
|
| Rate for Payer: MDX Hawaii PPO |
$18.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.77
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.77
|
| Rate for Payer: University Health Alliance Commercial |
$14.24
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
IP
|
$19.54
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$18.95 |
| Rate for Payer: Cash Price |
$12.70
|
| Rate for Payer: Health Management Network Commercial |
$16.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.59
|
| Rate for Payer: MDX Hawaii PPO |
$18.95
|
|
|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.95
|
| 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 [HHSC]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$3.88 |
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
