|
levETIRAcetam 500 mg tablet [HHSC]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 60687065701
|
| 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
|
IP
|
$17.59
|
|
|
Service Code
|
NDC 00904605261
|
| Hospital Charge Code |
2500459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$17.06 |
| Rate for Payer: Cash Price |
$11.43
|
| Rate for Payer: Health Management Network Commercial |
$14.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.83
|
| Rate for Payer: MDX Hawaii PPO |
$17.06
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
IP
|
$88.41
|
|
|
Service Code
|
NDC 72578009818
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.15 |
| Max. Negotiated Rate |
$85.76 |
| Rate for Payer: Cash Price |
$57.47
|
| Rate for Payer: Health Management Network Commercial |
$75.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.57
|
| Rate for Payer: MDX Hawaii PPO |
$85.76
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
OP
|
$87.09
|
|
|
Service Code
|
NDC 68084048101
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$84.48 |
| Rate for Payer: AlohaCare Medicaid |
$43.55
|
| Rate for Payer: AlohaCare Medicare |
$43.55
|
| Rate for Payer: Cash Price |
$56.61
|
| Rate for Payer: Devoted Health Medicare |
$47.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$43.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$82.74
|
| Rate for Payer: Health Management Network Commercial |
$74.03
|
| Rate for Payer: Humana Medicare |
$43.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$43.55
|
| Rate for Payer: MDX Hawaii PPO |
$84.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$43.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$52.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$43.55
|
| Rate for Payer: University Health Alliance Commercial |
$63.48
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
OP
|
$79.70
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.85 |
| Max. Negotiated Rate |
$77.31 |
| Rate for Payer: AlohaCare Medicaid |
$39.85
|
| Rate for Payer: AlohaCare Medicare |
$39.85
|
| Rate for Payer: Cash Price |
$51.81
|
| Rate for Payer: Devoted Health Medicare |
$43.84
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$39.85
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$75.72
|
| Rate for Payer: Health Management Network Commercial |
$67.75
|
| Rate for Payer: Humana Medicare |
$39.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.73
|
| Rate for Payer: Kaiser Permanente Medicaid |
$40.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$39.85
|
| Rate for Payer: MDX Hawaii PPO |
$77.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$39.85
|
| Rate for Payer: Ohana Health Plan Medicare |
$39.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$39.85
|
| Rate for Payer: University Health Alliance Commercial |
$58.09
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
OP
|
$88.42
|
|
|
Service Code
|
NDC 65862053650
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.21 |
| Max. Negotiated Rate |
$85.77 |
| Rate for Payer: AlohaCare Medicaid |
$44.21
|
| Rate for Payer: AlohaCare Medicare |
$44.21
|
| Rate for Payer: Cash Price |
$57.47
|
| Rate for Payer: Devoted Health Medicare |
$48.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$84.00
|
| Rate for Payer: Health Management Network Commercial |
$75.16
|
| Rate for Payer: Humana Medicare |
$44.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.21
|
| Rate for Payer: MDX Hawaii PPO |
$85.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.21
|
| Rate for Payer: University Health Alliance Commercial |
$64.45
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
OP
|
$88.41
|
|
|
Service Code
|
NDC 72578009818
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$85.76 |
| Rate for Payer: AlohaCare Medicaid |
$44.20
|
| Rate for Payer: AlohaCare Medicare |
$44.20
|
| Rate for Payer: Cash Price |
$57.47
|
| Rate for Payer: Devoted Health Medicare |
$48.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$44.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.99
|
| Rate for Payer: Health Management Network Commercial |
$75.15
|
| Rate for Payer: Humana Medicare |
$44.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.57
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$44.20
|
| Rate for Payer: MDX Hawaii PPO |
$85.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$44.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$44.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$53.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$44.20
|
| Rate for Payer: University Health Alliance Commercial |
$64.44
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
IP
|
$79.70
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.75 |
| Max. Negotiated Rate |
$77.31 |
| Rate for Payer: Cash Price |
$51.81
|
| Rate for Payer: Health Management Network Commercial |
$67.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$71.73
|
| Rate for Payer: MDX Hawaii PPO |
$77.31
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
IP
|
$87.09
|
|
|
Service Code
|
NDC 68084048101
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.03 |
| Max. Negotiated Rate |
$84.48 |
| Rate for Payer: Cash Price |
$56.61
|
| Rate for Payer: Health Management Network Commercial |
$74.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.38
|
| Rate for Payer: MDX Hawaii PPO |
$84.48
|
|
|
levofloxacin 250 mg tablet [HHSC]
|
Facility
|
IP
|
$88.42
|
|
|
Service Code
|
NDC 65862053650
|
| Hospital Charge Code |
2500461
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.16 |
| Max. Negotiated Rate |
$85.77 |
| Rate for Payer: Cash Price |
$57.47
|
| Rate for Payer: Health Management Network Commercial |
$75.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$79.58
|
| Rate for Payer: MDX Hawaii PPO |
$85.77
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
IP
|
$121.03
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.88 |
| Max. Negotiated Rate |
$117.40 |
| Rate for Payer: Cash Price |
$78.67
|
| Rate for Payer: Health Management Network Commercial |
$102.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.93
|
| Rate for Payer: MDX Hawaii PPO |
$117.40
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
OP
|
$121.03
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.52 |
| Max. Negotiated Rate |
$117.40 |
| Rate for Payer: AlohaCare Medicaid |
$60.52
|
| Rate for Payer: AlohaCare Medicare |
$60.52
|
| Rate for Payer: Cash Price |
$78.67
|
| Rate for Payer: Devoted Health Medicare |
$66.57
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$60.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$114.98
|
| Rate for Payer: Health Management Network Commercial |
$102.88
|
| Rate for Payer: Humana Medicare |
$60.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$108.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$61.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$60.52
|
| Rate for Payer: MDX Hawaii PPO |
$117.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$60.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$60.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$72.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$60.52
|
| Rate for Payer: University Health Alliance Commercial |
$88.22
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
IP
|
$168.95
|
|
|
Service Code
|
NDC 65862053820
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.61 |
| Max. Negotiated Rate |
$163.88 |
| Rate for Payer: Cash Price |
$109.82
|
| Rate for Payer: Health Management Network Commercial |
$143.61
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.06
|
| Rate for Payer: MDX Hawaii PPO |
$163.88
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
IP
|
$168.93
|
|
|
Service Code
|
NDC 72578010092
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.59 |
| Max. Negotiated Rate |
$163.86 |
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Health Management Network Commercial |
$143.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.04
|
| Rate for Payer: MDX Hawaii PPO |
$163.86
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
IP
|
$166.10
|
|
|
Service Code
|
NDC 68084048301
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$141.19 |
| Max. Negotiated Rate |
$161.12 |
| Rate for Payer: Cash Price |
$107.96
|
| Rate for Payer: Health Management Network Commercial |
$141.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.49
|
| Rate for Payer: MDX Hawaii PPO |
$161.12
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
OP
|
$168.93
|
|
|
Service Code
|
NDC 72578010092
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.47 |
| Max. Negotiated Rate |
$163.86 |
| Rate for Payer: AlohaCare Medicaid |
$84.47
|
| Rate for Payer: AlohaCare Medicare |
$84.47
|
| Rate for Payer: Cash Price |
$109.80
|
| Rate for Payer: Devoted Health Medicare |
$92.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$160.48
|
| Rate for Payer: Health Management Network Commercial |
$143.59
|
| Rate for Payer: Humana Medicare |
$84.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.04
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.47
|
| Rate for Payer: MDX Hawaii PPO |
$163.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.47
|
| Rate for Payer: University Health Alliance Commercial |
$123.13
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
OP
|
$168.95
|
|
|
Service Code
|
NDC 65862053820
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.47 |
| Max. Negotiated Rate |
$163.88 |
| Rate for Payer: AlohaCare Medicaid |
$84.47
|
| Rate for Payer: AlohaCare Medicare |
$84.47
|
| Rate for Payer: Cash Price |
$109.82
|
| Rate for Payer: Devoted Health Medicare |
$92.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$160.50
|
| Rate for Payer: Health Management Network Commercial |
$143.61
|
| Rate for Payer: Humana Medicare |
$84.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.47
|
| Rate for Payer: MDX Hawaii PPO |
$163.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.47
|
| Rate for Payer: University Health Alliance Commercial |
$123.15
|
|
|
levofloxacin 750 mg tablet [HHSC]
|
Facility
|
OP
|
$166.10
|
|
|
Service Code
|
NDC 68084048301
|
| Hospital Charge Code |
2500465
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$83.05 |
| Max. Negotiated Rate |
$161.12 |
| Rate for Payer: AlohaCare Medicaid |
$83.05
|
| Rate for Payer: AlohaCare Medicare |
$83.05
|
| Rate for Payer: Cash Price |
$107.96
|
| Rate for Payer: Devoted Health Medicare |
$91.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$157.79
|
| Rate for Payer: Health Management Network Commercial |
$141.19
|
| Rate for Payer: Humana Medicare |
$83.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$149.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$84.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$83.05
|
| Rate for Payer: MDX Hawaii PPO |
$161.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.05
|
| Rate for Payer: UnitedHealthcare Medicaid |
$99.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.05
|
| Rate for Payer: University Health Alliance Commercial |
$121.07
|
|
|
levofloxacin-d5w 500 mg/100 ml premix [HHSC]
|
Facility
|
OP
|
$13.90
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2500464
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: AlohaCare Medicaid |
$6.95
|
| Rate for Payer: AlohaCare Medicaid |
$36.66
|
| Rate for Payer: AlohaCare Medicaid |
$78.55
|
| Rate for Payer: AlohaCare Medicare |
$78.55
|
| Rate for Payer: AlohaCare Medicare |
$6.95
|
| Rate for Payer: AlohaCare Medicare |
$36.66
|
| Rate for Payer: Cash Price |
$102.11
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$102.11
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Devoted Health Medicare |
$7.64
|
| Rate for Payer: Devoted Health Medicare |
$40.33
|
| Rate for Payer: Devoted Health Medicare |
$86.40
|
| 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 |
$6.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.55
|
| 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 |
$149.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.66
|
| Rate for Payer: Health Management Network Commercial |
$62.33
|
| Rate for Payer: Health Management Network Commercial |
$11.81
|
| Rate for Payer: Health Management Network Commercial |
$133.53
|
| Rate for Payer: Humana Medicare |
$6.95
|
| Rate for Payer: Humana Medicare |
$78.55
|
| Rate for Payer: Humana Medicare |
$36.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.66
|
| Rate for Payer: MDX Hawaii PPO |
$71.13
|
| Rate for Payer: MDX Hawaii PPO |
$152.38
|
| Rate for Payer: MDX Hawaii PPO |
$13.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$94.25
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.66
|
| Rate for Payer: University Health Alliance Commercial |
$10.13
|
| Rate for Payer: University Health Alliance Commercial |
$114.50
|
| Rate for Payer: University Health Alliance Commercial |
$53.45
|
|
|
levofloxacin-d5w 500 mg/100 ml premix [HHSC]
|
Facility
|
IP
|
$73.33
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2500464
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.33 |
| Max. Negotiated Rate |
$71.13 |
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$102.11
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Health Management Network Commercial |
$11.81
|
| Rate for Payer: Health Management Network Commercial |
$62.33
|
| Rate for Payer: Health Management Network Commercial |
$133.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$141.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.51
|
| Rate for Payer: MDX Hawaii PPO |
$152.38
|
| Rate for Payer: MDX Hawaii PPO |
$13.48
|
| Rate for Payer: MDX Hawaii PPO |
$71.13
|
|
|
levofloxacin-d5w 750 mg/150 ml premix [HHSC]
|
Facility
|
IP
|
$46.11
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2500466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.19 |
| Max. Negotiated Rate |
$44.73 |
| Rate for Payer: Cash Price |
$29.97
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Health Management Network Commercial |
$12.53
|
| Rate for Payer: Health Management Network Commercial |
$39.19
|
| Rate for Payer: Health Management Network Commercial |
$40.52
|
| Rate for Payer: Health Management Network Commercial |
$62.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.30
|
| Rate for Payer: MDX Hawaii PPO |
$46.24
|
| Rate for Payer: MDX Hawaii PPO |
$71.13
|
| Rate for Payer: MDX Hawaii PPO |
$44.73
|
|
|
levofloxacin-d5w 750 mg/150 ml premix [HHSC]
|
Facility
|
OP
|
$47.67
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2500466
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$46.24 |
| Rate for Payer: AlohaCare Medicaid |
$23.84
|
| Rate for Payer: AlohaCare Medicaid |
$36.66
|
| Rate for Payer: AlohaCare Medicaid |
$23.05
|
| Rate for Payer: AlohaCare Medicaid |
$7.37
|
| Rate for Payer: AlohaCare Medicare |
$7.37
|
| Rate for Payer: AlohaCare Medicare |
$23.05
|
| Rate for Payer: AlohaCare Medicare |
$23.84
|
| Rate for Payer: AlohaCare Medicare |
$36.66
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Cash Price |
$29.97
|
| Rate for Payer: Cash Price |
$29.97
|
| Rate for Payer: Cash Price |
$30.99
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Cash Price |
$9.58
|
| Rate for Payer: Cash Price |
$47.66
|
| Rate for Payer: Devoted Health Medicare |
$25.36
|
| Rate for Payer: Devoted Health Medicare |
$26.22
|
| Rate for Payer: Devoted Health Medicare |
$8.11
|
| Rate for Payer: Devoted Health Medicare |
$40.33
|
| 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 ABD |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.66
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$23.84
|
| 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 Medical Service Association Non-ABD |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$45.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$43.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$69.66
|
| Rate for Payer: Health Management Network Commercial |
$62.33
|
| Rate for Payer: Health Management Network Commercial |
$39.19
|
| Rate for Payer: Health Management Network Commercial |
$12.53
|
| Rate for Payer: Health Management Network Commercial |
$40.52
|
| Rate for Payer: Humana Medicare |
$23.05
|
| Rate for Payer: Humana Medicare |
$7.37
|
| Rate for Payer: Humana Medicare |
$23.84
|
| Rate for Payer: Humana Medicare |
$36.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$66.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.31
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.66
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.37
|
| Rate for Payer: MDX Hawaii PPO |
$71.13
|
| Rate for Payer: MDX Hawaii PPO |
$46.24
|
| Rate for Payer: MDX Hawaii PPO |
$44.73
|
| Rate for Payer: MDX Hawaii PPO |
$14.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$23.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.05
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$23.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$27.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$28.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$44.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$23.05
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.37
|
| Rate for Payer: University Health Alliance Commercial |
$53.45
|
| Rate for Payer: University Health Alliance Commercial |
$34.75
|
| Rate for Payer: University Health Alliance Commercial |
$10.74
|
| Rate for Payer: University Health Alliance Commercial |
$33.61
|
|
|
levonorgestrel 1.5 mg tablet [HHSC]
|
Facility
|
IP
|
$179.09
|
|
|
Service Code
|
NDC 51285016288
|
| Hospital Charge Code |
2500467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.23 |
| Max. Negotiated Rate |
$173.72 |
| Rate for Payer: Cash Price |
$116.41
|
| Rate for Payer: Health Management Network Commercial |
$152.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.18
|
| Rate for Payer: MDX Hawaii PPO |
$173.72
|
|
|
levonorgestrel 1.5 mg tablet [HHSC]
|
Facility
|
OP
|
$179.09
|
|
|
Service Code
|
NDC 51285016288
|
| Hospital Charge Code |
2500467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.55 |
| Max. Negotiated Rate |
$173.72 |
| Rate for Payer: AlohaCare Medicaid |
$89.55
|
| Rate for Payer: AlohaCare Medicare |
$89.55
|
| Rate for Payer: Cash Price |
$116.41
|
| Rate for Payer: Devoted Health Medicare |
$98.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$89.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.14
|
| Rate for Payer: Health Management Network Commercial |
$152.23
|
| Rate for Payer: Humana Medicare |
$89.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$161.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$91.34
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.55
|
| Rate for Payer: MDX Hawaii PPO |
$173.72
|
| Rate for Payer: Ohana Health Plan Medicaid |
$89.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$89.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$107.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$89.55
|
| Rate for Payer: University Health Alliance Commercial |
$130.54
|
|
|
levonorgestrel 1.5 mg tablet [HHSC]
|
Facility
|
OP
|
$171.40
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
2500467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$85.70 |
| Max. Negotiated Rate |
$166.26 |
| Rate for Payer: AlohaCare Medicaid |
$85.70
|
| Rate for Payer: AlohaCare Medicare |
$85.70
|
| Rate for Payer: Cash Price |
$111.41
|
| Rate for Payer: Devoted Health Medicare |
$94.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$85.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$162.83
|
| Rate for Payer: Health Management Network Commercial |
$145.69
|
| Rate for Payer: Humana Medicare |
$85.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$87.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$85.70
|
| Rate for Payer: MDX Hawaii PPO |
$166.26
|
| Rate for Payer: Ohana Health Plan Medicaid |
$85.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$85.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$102.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$85.70
|
| Rate for Payer: University Health Alliance Commercial |
$124.93
|
|
