|
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV IVPB
|
Facility
|
IP
|
$75.96
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$64.57 |
| Max. Negotiated Rate |
$73.68 |
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Health Management Network Commercial |
$64.57
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.36
|
| Rate for Payer: MDX Hawaii PPO |
$73.68
|
|
|
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV IVPB
|
Facility
|
OP
|
$75.96
|
|
|
Service Code
|
HCPCS J1953
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$75.20 |
| Rate for Payer: AlohaCare Medicaid |
$37.98
|
| Rate for Payer: AlohaCare Medicare |
$68.36
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Cash Price |
$49.37
|
| Rate for Payer: Devoted Health Medicare |
$75.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$68.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.05
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$72.16
|
| Rate for Payer: Health Management Network Commercial |
$64.57
|
| Rate for Payer: Humana Medicare |
$68.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$68.36
|
| Rate for Payer: Kaiser Permanente Medicaid |
$38.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$68.36
|
| Rate for Payer: MDX Hawaii PPO |
$73.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$68.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$68.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$45.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$68.36
|
| Rate for Payer: University Health Alliance Commercial |
$55.37
|
|
|
LEVOFLOXACIN 250 MG PO TABLET
|
Facility
|
OP
|
$87.60
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.80 |
| Max. Negotiated Rate |
$86.72 |
| Rate for Payer: AlohaCare Medicaid |
$43.80
|
| Rate for Payer: AlohaCare Medicare |
$78.84
|
| Rate for Payer: Cash Price |
$56.94
|
| Rate for Payer: Devoted Health Medicare |
$86.72
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$78.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$83.22
|
| Rate for Payer: Health Management Network Commercial |
$74.46
|
| Rate for Payer: Humana Medicare |
$78.84
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$44.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$78.84
|
| Rate for Payer: MDX Hawaii PPO |
$84.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$78.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$78.84
|
| Rate for Payer: UnitedHealthcare Medicare |
$78.84
|
| Rate for Payer: University Health Alliance Commercial |
$63.85
|
|
|
LEVOFLOXACIN 250 MG PO TABLET
|
Facility
|
IP
|
$87.60
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$74.46 |
| Max. Negotiated Rate |
$84.97 |
| Rate for Payer: Cash Price |
$56.94
|
| Rate for Payer: Health Management Network Commercial |
$74.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$78.84
|
| Rate for Payer: MDX Hawaii PPO |
$84.97
|
|
|
LEVOFLOXACIN 500 MG PO TABLET
|
Facility
|
IP
|
$1.35
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.31 |
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cash Price |
$63.55
|
| Rate for Payer: Health Management Network Commercial |
$1.15
|
| Rate for Payer: Health Management Network Commercial |
$83.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.99
|
| Rate for Payer: MDX Hawaii PPO |
$94.84
|
| Rate for Payer: MDX Hawaii PPO |
$1.31
|
|
|
LEVOFLOXACIN 500 MG PO TABLET
|
Facility
|
OP
|
$97.77
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.88 |
| Max. Negotiated Rate |
$96.79 |
| Rate for Payer: AlohaCare Medicaid |
$48.88
|
| Rate for Payer: AlohaCare Medicaid |
$0.68
|
| Rate for Payer: AlohaCare Medicare |
$1.22
|
| Rate for Payer: AlohaCare Medicare |
$87.99
|
| Rate for Payer: Cash Price |
$0.88
|
| Rate for Payer: Cash Price |
$63.55
|
| Rate for Payer: Devoted Health Medicare |
$96.79
|
| Rate for Payer: Devoted Health Medicare |
$1.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$92.88
|
| Rate for Payer: Health Management Network Commercial |
$83.10
|
| Rate for Payer: Health Management Network Commercial |
$1.15
|
| Rate for Payer: Humana Medicare |
$87.99
|
| Rate for Payer: Humana Medicare |
$1.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$87.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$0.69
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.22
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.99
|
| Rate for Payer: MDX Hawaii PPO |
$1.31
|
| Rate for Payer: MDX Hawaii PPO |
$94.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.99
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.22
|
| Rate for Payer: University Health Alliance Commercial |
$71.26
|
| Rate for Payer: University Health Alliance Commercial |
$0.98
|
|
|
LEVOFLOXACIN 750 MG PO TABLET
|
Facility
|
OP
|
$167.35
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.67 |
| Max. Negotiated Rate |
$165.68 |
| Rate for Payer: AlohaCare Medicaid |
$83.67
|
| Rate for Payer: AlohaCare Medicare |
$150.62
|
| Rate for Payer: Cash Price |
$108.78
|
| Rate for Payer: Devoted Health Medicare |
$165.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$150.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$158.98
|
| Rate for Payer: Health Management Network Commercial |
$142.25
|
| Rate for Payer: Humana Medicare |
$150.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$85.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$150.62
|
| Rate for Payer: MDX Hawaii PPO |
$162.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$150.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$150.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$150.62
|
| Rate for Payer: University Health Alliance Commercial |
$121.98
|
|
|
LEVOFLOXACIN 750 MG PO TABLET
|
Facility
|
IP
|
$167.35
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$142.25 |
| Max. Negotiated Rate |
$162.33 |
| Rate for Payer: Cash Price |
$108.78
|
| Rate for Payer: Health Management Network Commercial |
$142.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$150.62
|
| Rate for Payer: MDX Hawaii PPO |
$162.33
|
|
|
LEVOFLOXACIN IN D5W 250 MG/50 ML IVPB
|
Facility
|
IP
|
$23.19
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.71 |
| Max. Negotiated Rate |
$22.49 |
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Health Management Network Commercial |
$19.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.87
|
| Rate for Payer: MDX Hawaii PPO |
$22.49
|
|
|
LEVOFLOXACIN IN D5W 250 MG/50 ML IVPB
|
Facility
|
OP
|
$23.19
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$22.96 |
| Rate for Payer: AlohaCare Medicaid |
$11.60
|
| Rate for Payer: AlohaCare Medicare |
$20.87
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Cash Price |
$15.07
|
| Rate for Payer: Devoted Health Medicare |
$22.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.87
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.03
|
| Rate for Payer: Health Management Network Commercial |
$19.71
|
| Rate for Payer: Humana Medicare |
$20.87
|
| Rate for Payer: Kaiser Permanente Commercial |
$20.87
|
| Rate for Payer: Kaiser Permanente Medicaid |
$11.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.87
|
| Rate for Payer: MDX Hawaii PPO |
$22.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.87
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.87
|
| Rate for Payer: University Health Alliance Commercial |
$16.90
|
|
|
LEVOFLOXACIN IN D5W 500 MG/100 ML IV IVPB
|
Facility
|
OP
|
$32.02
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$31.70 |
| Rate for Payer: AlohaCare Medicaid |
$16.01
|
| Rate for Payer: AlohaCare Medicaid |
$19.55
|
| Rate for Payer: AlohaCare Medicare |
$35.19
|
| Rate for Payer: AlohaCare Medicare |
$28.82
|
| Rate for Payer: Cash Price |
$25.42
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$25.42
|
| Rate for Payer: Devoted Health Medicare |
$31.70
|
| Rate for Payer: Devoted Health Medicare |
$38.71
|
| 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 |
$35.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.82
|
| 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 |
$30.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$37.15
|
| Rate for Payer: Health Management Network Commercial |
$33.23
|
| Rate for Payer: Health Management Network Commercial |
$27.22
|
| Rate for Payer: Humana Medicare |
$28.82
|
| Rate for Payer: Humana Medicare |
$35.19
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.19
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$35.19
|
| Rate for Payer: MDX Hawaii PPO |
$31.06
|
| Rate for Payer: MDX Hawaii PPO |
$37.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$35.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$35.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.82
|
| Rate for Payer: UnitedHealthcare Medicare |
$35.19
|
| Rate for Payer: University Health Alliance Commercial |
$23.34
|
| Rate for Payer: University Health Alliance Commercial |
$28.50
|
|
|
LEVOFLOXACIN IN D5W 500 MG/100 ML IV IVPB
|
Facility
|
IP
|
$32.02
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.22 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cash Price |
$25.42
|
| Rate for Payer: Health Management Network Commercial |
$27.22
|
| Rate for Payer: Health Management Network Commercial |
$33.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$28.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.19
|
| Rate for Payer: MDX Hawaii PPO |
$37.93
|
| Rate for Payer: MDX Hawaii PPO |
$31.06
|
|
|
LEVOFLOXACIN IN D5W 750 MG/150 ML IV IVPB
|
Facility
|
OP
|
$40.07
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$39.67 |
| Rate for Payer: AlohaCare Medicaid |
$20.04
|
| Rate for Payer: AlohaCare Medicare |
$36.06
|
| Rate for Payer: Cash Price |
$26.05
|
| Rate for Payer: Cash Price |
$26.05
|
| Rate for Payer: Devoted Health Medicare |
$39.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$36.06
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.07
|
| Rate for Payer: Health Management Network Commercial |
$34.06
|
| Rate for Payer: Humana Medicare |
$36.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.06
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$36.06
|
| Rate for Payer: MDX Hawaii PPO |
$38.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$36.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$36.06
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$36.06
|
| Rate for Payer: University Health Alliance Commercial |
$29.21
|
|
|
LEVOFLOXACIN IN D5W 750 MG/150 ML IV IVPB
|
Facility
|
IP
|
$40.07
|
|
|
Service Code
|
HCPCS J1956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.06 |
| Max. Negotiated Rate |
$38.87 |
| Rate for Payer: Cash Price |
$26.05
|
| Rate for Payer: Health Management Network Commercial |
$34.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.06
|
| Rate for Payer: MDX Hawaii PPO |
$38.87
|
|
|
LEVONORGESTREL 1.5 MG PO TABLET
|
Facility
|
IP
|
$152.55
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$129.67 |
| Max. Negotiated Rate |
$147.97 |
| Rate for Payer: Cash Price |
$99.16
|
| Rate for Payer: Health Management Network Commercial |
$129.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.29
|
| Rate for Payer: MDX Hawaii PPO |
$147.97
|
|
|
LEVONORGESTREL 1.5 MG PO TABLET
|
Facility
|
OP
|
$152.55
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.28 |
| Max. Negotiated Rate |
$151.02 |
| Rate for Payer: AlohaCare Medicaid |
$76.28
|
| Rate for Payer: AlohaCare Medicare |
$137.29
|
| Rate for Payer: Cash Price |
$99.16
|
| Rate for Payer: Devoted Health Medicare |
$151.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$137.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.92
|
| Rate for Payer: Health Management Network Commercial |
$129.67
|
| Rate for Payer: Humana Medicare |
$137.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$137.29
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$137.29
|
| Rate for Payer: MDX Hawaii PPO |
$147.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$137.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$137.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$137.29
|
| Rate for Payer: University Health Alliance Commercial |
$111.19
|
|
|
LEVOTHYROXINE 100 MCG PO TABLET
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
HCPCS A9270
|
|
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
|
|
|
LEVOTHYROXINE 100 MCG PO TABLET
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$3.96 |
| Rate for Payer: AlohaCare Medicaid |
$2.00
|
| Rate for Payer: AlohaCare Medicare |
$3.60
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Devoted Health Medicare |
$3.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.80
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Humana Medicare |
$3.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.60
|
| Rate for Payer: University Health Alliance Commercial |
$2.92
|
|
|
LEVOTHYROXINE 25 MCG PO TABLET
|
Facility
|
OP
|
$3.09
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: AlohaCare Medicaid |
$1.54
|
| Rate for Payer: AlohaCare Medicare |
$2.78
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.94
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Humana Medicare |
$2.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.78
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.78
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.78
|
| Rate for Payer: University Health Alliance Commercial |
$2.25
|
|
|
LEVOTHYROXINE 25 MCG PO TABLET
|
Facility
|
IP
|
$3.09
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Health Management Network Commercial |
$2.63
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.78
|
| Rate for Payer: MDX Hawaii PPO |
$3.00
|
|
|
LEVOTHYROXINE 50 MCG PO TABLET
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: AlohaCare Medicaid |
$1.37
|
| Rate for Payer: AlohaCare Medicaid |
$1.56
|
| Rate for Payer: AlohaCare Medicare |
$2.47
|
| Rate for Payer: AlohaCare Medicare |
$2.81
|
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Devoted Health Medicare |
$2.71
|
| Rate for Payer: Devoted Health Medicare |
$3.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.47
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.60
|
| Rate for Payer: Health Management Network Commercial |
$2.33
|
| Rate for Payer: Health Management Network Commercial |
$2.65
|
| Rate for Payer: Humana Medicare |
$2.81
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.81
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.47
|
| Rate for Payer: MDX Hawaii PPO |
$3.03
|
| Rate for Payer: MDX Hawaii PPO |
$2.66
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.47
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.81
|
| Rate for Payer: University Health Alliance Commercial |
$2.27
|
| Rate for Payer: University Health Alliance Commercial |
$2.00
|
|
|
LEVOTHYROXINE 50 MCG PO TABLET
|
Facility
|
IP
|
$3.12
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.65 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Cash Price |
$2.03
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Health Management Network Commercial |
$2.65
|
| Rate for Payer: Health Management Network Commercial |
$2.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.47
|
| Rate for Payer: MDX Hawaii PPO |
$2.66
|
| Rate for Payer: MDX Hawaii PPO |
$3.03
|
|
|
LEVOTHYROXINE 75 MCG PO TABLET
|
Facility
|
IP
|
$3.90
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$3.78 |
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Health Management Network Commercial |
$2.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.96
|
| Rate for Payer: MDX Hawaii PPO |
$3.19
|
| Rate for Payer: MDX Hawaii PPO |
$3.78
|
|
|
LEVOTHYROXINE 75 MCG PO TABLET
|
Facility
|
OP
|
$3.29
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.26 |
| Rate for Payer: AlohaCare Medicaid |
$1.65
|
| Rate for Payer: AlohaCare Medicaid |
$1.95
|
| Rate for Payer: AlohaCare Medicare |
$2.96
|
| Rate for Payer: AlohaCare Medicare |
$3.51
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Devoted Health Medicare |
$3.26
|
| Rate for Payer: Devoted Health Medicare |
$3.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.51
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.13
|
| Rate for Payer: Health Management Network Commercial |
$2.80
|
| Rate for Payer: Health Management Network Commercial |
$3.31
|
| Rate for Payer: Humana Medicare |
$3.51
|
| Rate for Payer: Humana Medicare |
$2.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.96
|
| Rate for Payer: MDX Hawaii PPO |
$3.78
|
| Rate for Payer: MDX Hawaii PPO |
$3.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.51
|
| Rate for Payer: University Health Alliance Commercial |
$2.84
|
| Rate for Payer: University Health Alliance Commercial |
$2.40
|
|
|
LEVOTHYROXINE 88 MCG PO TABLET
|
Facility
|
IP
|
$3.87
|
|
|
Service Code
|
HCPCS A9270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.29 |
| Max. Negotiated Rate |
$3.75 |
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Health Management Network Commercial |
$3.29
|
| Rate for Payer: Health Management Network Commercial |
$2.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.02
|
| Rate for Payer: MDX Hawaii PPO |
$3.26
|
| Rate for Payer: MDX Hawaii PPO |
$3.75
|
|
