|
levonorgestrel 1.5 mg tablet [HHSC]
|
Facility
|
IP
|
$171.40
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
2500467
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.69 |
| Max. Negotiated Rate |
$166.26 |
| Rate for Payer: Cash Price |
$111.41
|
| Rate for Payer: Health Management Network Commercial |
$145.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$154.26
|
| Rate for Payer: MDX Hawaii PPO |
$166.26
|
|
|
levonorgestrel 52 mg IUD [HHSC]
|
Facility
|
OP
|
$23,975.31
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
2501212
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,214.63 |
| Max. Negotiated Rate |
$23,256.05 |
| Rate for Payer: AlohaCare Medicaid |
$11,987.66
|
| Rate for Payer: AlohaCare Medicare |
$11,987.66
|
| Rate for Payer: Cash Price |
$15,583.95
|
| Rate for Payer: Cash Price |
$15,583.95
|
| Rate for Payer: Devoted Health Medicare |
$13,186.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1,214.63
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,987.66
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1,214.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22,776.54
|
| Rate for Payer: Health Management Network Commercial |
$20,379.01
|
| Rate for Payer: Humana Medicare |
$11,987.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$21,577.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12,227.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,987.66
|
| Rate for Payer: MDX Hawaii PPO |
$23,256.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,987.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,987.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14,385.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,987.66
|
| Rate for Payer: University Health Alliance Commercial |
$17,475.60
|
|
|
levonorgestrel 52 mg IUD [HHSC]
|
Facility
|
IP
|
$23,975.31
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
2501212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20,379.01 |
| Max. Negotiated Rate |
$23,256.05 |
| Rate for Payer: Cash Price |
$15,583.95
|
| Rate for Payer: Health Management Network Commercial |
$20,379.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$21,577.78
|
| Rate for Payer: MDX Hawaii PPO |
$23,256.05
|
|
|
levothyroxine 100 mcg/5 mL vial [HHSC]
|
Facility
|
IP
|
$520.03
|
|
|
Service Code
|
NDC 63323088510
|
| Hospital Charge Code |
2501025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$442.03 |
| Max. Negotiated Rate |
$504.43 |
| Rate for Payer: Cash Price |
$338.02
|
| Rate for Payer: Health Management Network Commercial |
$442.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$468.03
|
| Rate for Payer: MDX Hawaii PPO |
$504.43
|
|
|
levothyroxine 100 mcg/5 mL vial [HHSC]
|
Facility
|
IP
|
$413.35
|
|
|
Service Code
|
NDC 63323088514
|
| Hospital Charge Code |
2501025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$351.35 |
| Max. Negotiated Rate |
$400.95 |
| Rate for Payer: Cash Price |
$268.68
|
| Rate for Payer: Health Management Network Commercial |
$351.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$372.01
|
| Rate for Payer: MDX Hawaii PPO |
$400.95
|
|
|
levothyroxine 100 mcg/5 mL vial [HHSC]
|
Facility
|
OP
|
$520.03
|
|
|
Service Code
|
NDC 63323088510
|
| Hospital Charge Code |
2501025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$260.01 |
| Max. Negotiated Rate |
$504.43 |
| Rate for Payer: AlohaCare Medicaid |
$260.01
|
| Rate for Payer: AlohaCare Medicare |
$260.01
|
| Rate for Payer: Cash Price |
$338.02
|
| Rate for Payer: Devoted Health Medicare |
$286.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$260.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$494.03
|
| Rate for Payer: Health Management Network Commercial |
$442.03
|
| Rate for Payer: Humana Medicare |
$260.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$468.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$265.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$260.01
|
| Rate for Payer: MDX Hawaii PPO |
$504.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$260.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$260.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$312.02
|
| Rate for Payer: UnitedHealthcare Medicare |
$260.01
|
| Rate for Payer: University Health Alliance Commercial |
$379.05
|
|
|
levothyroxine 100 mcg/5 mL vial [HHSC]
|
Facility
|
OP
|
$413.35
|
|
|
Service Code
|
NDC 63323088514
|
| Hospital Charge Code |
2501025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$206.68 |
| Max. Negotiated Rate |
$400.95 |
| Rate for Payer: AlohaCare Medicaid |
$206.68
|
| Rate for Payer: AlohaCare Medicare |
$206.68
|
| Rate for Payer: Cash Price |
$268.68
|
| Rate for Payer: Devoted Health Medicare |
$227.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$206.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$392.68
|
| Rate for Payer: Health Management Network Commercial |
$351.35
|
| Rate for Payer: Humana Medicare |
$206.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$372.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$210.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$206.68
|
| Rate for Payer: MDX Hawaii PPO |
$400.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$206.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$206.68
|
| Rate for Payer: UnitedHealthcare Medicaid |
$248.01
|
| Rate for Payer: UnitedHealthcare Medicare |
$206.68
|
| Rate for Payer: University Health Alliance Commercial |
$301.29
|
|
|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
OP
|
$4.02
|
|
|
Service Code
|
NDC 60687049701
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: AlohaCare Medicaid |
$2.01
|
| Rate for Payer: AlohaCare Medicare |
$2.01
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Devoted Health Medicare |
$2.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.82
|
| Rate for Payer: Health Management Network Commercial |
$3.42
|
| Rate for Payer: Humana Medicare |
$2.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.01
|
| Rate for Payer: MDX Hawaii PPO |
$3.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.01
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.01
|
| Rate for Payer: University Health Alliance Commercial |
$2.93
|
|
|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Health Management Network Commercial |
$2.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.11
|
| Rate for Payer: MDX Hawaii PPO |
$3.36
|
|
|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.46
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: AlohaCare Medicaid |
$1.73
|
| Rate for Payer: AlohaCare Medicare |
$1.73
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Devoted Health Medicare |
$1.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.29
|
| Rate for Payer: Health Management Network Commercial |
$2.94
|
| Rate for Payer: Humana Medicare |
$1.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.11
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.76
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.73
|
| Rate for Payer: MDX Hawaii PPO |
$3.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.73
|
| Rate for Payer: University Health Alliance Commercial |
$2.52
|
|
|
levothyroxine 100 mcg tablet [HHSC]
|
Facility
|
IP
|
$4.02
|
|
|
Service Code
|
NDC 60687049701
|
| Hospital Charge Code |
2500469
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Health Management Network Commercial |
$3.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.62
|
| Rate for Payer: MDX Hawaii PPO |
$3.90
|
|
|
levothyroxine 25 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
2500471
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.64 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Health Management Network Commercial |
$2.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.80
|
| Rate for Payer: MDX Hawaii PPO |
$3.02
|
|
|
levothyroxine 25 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
2500471
|
|
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
|
|
|
levothyroxine 25 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
2500471
|
|
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
|
|
|
levothyroxine 25 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
2500471
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.02 |
| Rate for Payer: AlohaCare Medicaid |
$1.55
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Devoted Health Medicare |
$1.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.95
|
| Rate for Payer: Health Management Network Commercial |
$2.64
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.59
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$3.02
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$2.27
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.05
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: AlohaCare Medicaid |
$1.52
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Devoted Health Medicare |
$1.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.52
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.90
|
| Rate for Payer: Health Management Network Commercial |
$2.59
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$2.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$2.22
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.14
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Health Management Network Commercial |
$2.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.83
|
| Rate for Payer: MDX Hawaii PPO |
$3.05
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.14
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: AlohaCare Medicaid |
$1.57
|
| Rate for Payer: AlohaCare Medicare |
$1.57
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Devoted Health Medicare |
$1.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.57
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.98
|
| Rate for Payer: Health Management Network Commercial |
$2.67
|
| Rate for Payer: Humana Medicare |
$1.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.57
|
| Rate for Payer: MDX Hawaii PPO |
$3.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.57
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.57
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.57
|
| Rate for Payer: University Health Alliance Commercial |
$2.29
|
|
|
levothyroxine 50 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
2500472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.59 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Health Management Network Commercial |
$2.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.75
|
| Rate for Payer: MDX Hawaii PPO |
$2.96
|
|
|
levothyroxine 88 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.89
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
2500473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: AlohaCare Medicaid |
$1.95
|
| Rate for Payer: AlohaCare Medicare |
$1.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Devoted Health Medicare |
$2.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.70
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Humana Medicare |
$1.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.95
|
| Rate for Payer: MDX Hawaii PPO |
$3.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.95
|
| Rate for Payer: University Health Alliance Commercial |
$2.84
|
|
|
levothyroxine 88 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.89
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
2500473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$3.77 |
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.50
|
| Rate for Payer: MDX Hawaii PPO |
$3.77
|
|
|
levothyroxine 88 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
2500473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$3.01
|
|
|
levothyroxine 88 mcg tablet [HHSC]
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 00527134401
|
| Hospital Charge Code |
2500473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$3.01
|
|
|
levothyroxine 88 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 00527134401
|
| Hospital Charge Code |
2500473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: AlohaCare Medicaid |
$1.55
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Devoted Health Medicare |
$1.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.94
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$3.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicaid |
$1.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$2.26
|
|
|
levothyroxine 88 mcg tablet [HHSC]
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
2500473
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.55 |
| Max. Negotiated Rate |
$3.01 |
| Rate for Payer: UnitedHealthcare Medicaid |
$1.86
|
| Rate for Payer: AlohaCare Medicaid |
$1.55
|
| Rate for Payer: AlohaCare Medicare |
$1.55
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Devoted Health Medicare |
$1.71
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.55
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.94
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Humana Medicare |
$1.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.79
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.55
|
| Rate for Payer: MDX Hawaii PPO |
$3.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.55
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.55
|
| Rate for Payer: University Health Alliance Commercial |
$2.26
|
|
