|
Lead Blood (Capillary) FSI
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 83655
|
| Hospital Charge Code |
8117979
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$70.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Devoted Health Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.11
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Humana Medicare |
$70.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.00
|
| Rate for Payer: University Health Alliance Commercial |
$31.28
|
|
|
Lead Blood (Venous) FSI
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 83655
|
| Hospital Charge Code |
8117980
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$70.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Devoted Health Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.11
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Humana Medicare |
$70.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.00
|
| Rate for Payer: University Health Alliance Commercial |
$31.28
|
|
|
Lead Blood (Venous) FSI
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 83655
|
| Hospital Charge Code |
8117980
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
|
|
Lead, Blood (Venous) FSI
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 83655
|
| Hospital Charge Code |
12215068
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$119.00 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
|
|
Lead, Blood (Venous) FSI
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 83655
|
| Hospital Charge Code |
12215068
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$135.80 |
| Rate for Payer: AlohaCare Medicaid |
$70.00
|
| Rate for Payer: AlohaCare Medicare |
$70.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Devoted Health Medicare |
$77.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.72
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$15.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$70.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12.11
|
| Rate for Payer: Health Management Network Commercial |
$119.00
|
| Rate for Payer: Humana Medicare |
$70.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$126.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$71.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.00
|
| Rate for Payer: MDX Hawaii PPO |
$135.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$70.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$70.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$70.00
|
| Rate for Payer: University Health Alliance Commercial |
$31.28
|
|
|
Legionella pneumophila Antigen, Urine FSI
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS 87449
|
| Hospital Charge Code |
10408967
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: AlohaCare Medicaid |
$122.50
|
| Rate for Payer: AlohaCare Medicare |
$122.50
|
| Rate for Payer: Cash Price |
$159.25
|
| Rate for Payer: Cash Price |
$159.25
|
| Rate for Payer: Devoted Health Medicare |
$134.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.58
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$14.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$122.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$17.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.98
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Humana Medicare |
$122.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$124.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$122.50
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$122.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$122.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$122.50
|
| Rate for Payer: University Health Alliance Commercial |
$31.01
|
|
|
Legionella pneumophila Antigen, Urine FSI
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS 87449
|
| Hospital Charge Code |
10408967
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$208.25 |
| Max. Negotiated Rate |
$237.65 |
| Rate for Payer: Cash Price |
$159.25
|
| Rate for Payer: Health Management Network Commercial |
$208.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.50
|
| Rate for Payer: MDX Hawaii PPO |
$237.65
|
|
|
Leptin FSI
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
10046565
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.80 |
| Max. Negotiated Rate |
$143.56 |
| Rate for Payer: Cash Price |
$96.20
|
| Rate for Payer: Health Management Network Commercial |
$125.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.20
|
| Rate for Payer: MDX Hawaii PPO |
$143.56
|
|
|
Leptin FSI
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
HCPCS 83520
|
| Hospital Charge Code |
10046565
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$143.56 |
| Rate for Payer: AlohaCare Medicaid |
$74.00
|
| Rate for Payer: AlohaCare Medicare |
$74.00
|
| Rate for Payer: Cash Price |
$96.20
|
| Rate for Payer: Cash Price |
$96.20
|
| Rate for Payer: Devoted Health Medicare |
$81.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$17.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$18.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.27
|
| Rate for Payer: Health Management Network Commercial |
$125.80
|
| Rate for Payer: Humana Medicare |
$74.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$133.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$75.48
|
| Rate for Payer: Kaiser Permanente Medicare |
$74.00
|
| Rate for Payer: MDX Hawaii PPO |
$143.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$74.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.00
|
| Rate for Payer: University Health Alliance Commercial |
$33.47
|
|
|
Leptospira Antibody FSI
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS 86720
|
| Hospital Charge Code |
8228890
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$161.50 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Health Management Network Commercial |
$161.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.00
|
| Rate for Payer: MDX Hawaii PPO |
$184.30
|
|
|
Leptospira Antibody FSI
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
HCPCS 86720
|
| Hospital Charge Code |
8228890
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$184.30 |
| Rate for Payer: AlohaCare Medicaid |
$95.00
|
| Rate for Payer: AlohaCare Medicare |
$95.00
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Devoted Health Medicare |
$104.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.23
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$20.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$95.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16.20
|
| Rate for Payer: Health Management Network Commercial |
$161.50
|
| Rate for Payer: Humana Medicare |
$95.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$171.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$96.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$95.00
|
| Rate for Payer: MDX Hawaii PPO |
$184.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$95.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$95.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$95.00
|
| Rate for Payer: University Health Alliance Commercial |
$34.10
|
|
|
levalbuterol 0.63 mg/3 ml neb soln [HHSC]
|
Facility
|
IP
|
$41.04
|
|
|
Service Code
|
HCPCS J7614
|
| Hospital Charge Code |
2500453
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.88 |
| Max. Negotiated Rate |
$39.81 |
| Rate for Payer: Cash Price |
$26.68
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cash Price |
$27.51
|
| Rate for Payer: Health Management Network Commercial |
$35.98
|
| Rate for Payer: Health Management Network Commercial |
$9.45
|
| Rate for Payer: Health Management Network Commercial |
$34.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.94
|
| Rate for Payer: MDX Hawaii PPO |
$39.81
|
| Rate for Payer: MDX Hawaii PPO |
$10.79
|
| Rate for Payer: MDX Hawaii PPO |
$41.06
|
|
|
levalbuterol 0.63 mg/3 ml neb soln [HHSC]
|
Facility
|
OP
|
$41.04
|
|
|
Service Code
|
HCPCS J7614
|
| Hospital Charge Code |
2500453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$39.81 |
| Rate for Payer: AlohaCare Medicaid |
$20.52
|
| Rate for Payer: AlohaCare Medicaid |
$21.16
|
| Rate for Payer: AlohaCare Medicaid |
$5.56
|
| Rate for Payer: AlohaCare Medicare |
$21.16
|
| Rate for Payer: AlohaCare Medicare |
$5.56
|
| Rate for Payer: AlohaCare Medicare |
$20.52
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cash Price |
$27.51
|
| Rate for Payer: Cash Price |
$7.23
|
| Rate for Payer: Cash Price |
$27.51
|
| Rate for Payer: Cash Price |
$26.68
|
| Rate for Payer: Cash Price |
$26.68
|
| Rate for Payer: Devoted Health Medicare |
$23.28
|
| Rate for Payer: Devoted Health Medicare |
$22.57
|
| Rate for Payer: Devoted Health Medicare |
$6.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.56
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10.56
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.99
|
| Rate for Payer: Health Management Network Commercial |
$9.45
|
| Rate for Payer: Health Management Network Commercial |
$34.88
|
| Rate for Payer: Health Management Network Commercial |
$35.98
|
| Rate for Payer: Humana Medicare |
$20.52
|
| Rate for Payer: Humana Medicare |
$5.56
|
| Rate for Payer: Humana Medicare |
$21.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.94
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$21.16
|
| Rate for Payer: MDX Hawaii PPO |
$41.06
|
| Rate for Payer: MDX Hawaii PPO |
$10.79
|
| Rate for Payer: MDX Hawaii PPO |
$39.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.67
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.62
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.52
|
| Rate for Payer: University Health Alliance Commercial |
$30.85
|
| Rate for Payer: University Health Alliance Commercial |
$29.91
|
| Rate for Payer: University Health Alliance Commercial |
$8.11
|
|
|
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: MDX Hawaii PPO |
$51.05
|
| 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 |
$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 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
|
|
|
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
|
$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
|
$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
|
$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
|
$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
|
$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
|
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
|
|
|
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
|
$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
|
|
