|
PHENYLEPHRINE 2.5 % EYE DROPS [6246]
|
Facility
|
IP
|
$338.00
|
|
|
Service Code
|
NDC 70756064935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$287.30 |
| Max. Negotiated Rate |
$327.86 |
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Health Management Network Commercial |
$287.30
|
| Rate for Payer: MDX Hawaii PPO |
$327.86
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS [6246]
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
NDC 70756064935
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.38 |
| Max. Negotiated Rate |
$327.86 |
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$321.10
|
| Rate for Payer: Health Management Network Commercial |
$287.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.38
|
| Rate for Payer: MDX Hawaii PPO |
$327.86
|
| Rate for Payer: University Health Alliance Commercial |
$246.37
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [37993]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 60687027562
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [37993]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687027566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [37993]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687027562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [37993]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
NDC 60687027566
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51672414601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.26
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 51672414601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 65862069201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 65162021210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51672411101
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 51672411101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65162021210
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65862069201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 00071374066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 58151011801
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
NDC 00071374066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.41
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE [11019]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
NDC 58151011801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.95 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
|
PHOSPHORIC ACID 37% 1126979
|
Facility
|
OP
|
$132.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$67.32 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$83.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: University Health Alliance Commercial |
$96.21
|
|
|
PHOSPHORIC ACID 37% 1126979
|
Facility
|
IP
|
$132.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [8718]
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$112.10
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$74.34
|
| Rate for Payer: Kaiser Permanente Medicaid |
$60.18
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$70.80
|
| Rate for Payer: University Health Alliance Commercial |
$86.01
|
|
|
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION [8718]
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$114.46 |
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Health Management Network Commercial |
$100.30
|
| Rate for Payer: MDX Hawaii PPO |
$114.46
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [41624]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SOLUTION [41624]
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$17.46 |
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.84
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Health Management Network Commercial |
$15.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$5.67
|
| Rate for Payer: Kaiser Permanente Commercial |
$11.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: MDX Hawaii PPO |
$17.46
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.00
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
| Rate for Payer: University Health Alliance Commercial |
$13.12
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
PHYTONADIONE (VITAMIN K) 1 MG/ML ORAL SOLUTION [4080281]
|
Facility
|
IP
|
$74.00
|
|
|
Service Code
|
HCPCS J3430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.90 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Cash Price |
$44.40
|
| Rate for Payer: Health Management Network Commercial |
$62.90
|
| Rate for Payer: MDX Hawaii PPO |
$71.78
|
|
