|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904657561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| 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 |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
NDC 00904657561
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 63739029410
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENOBARBITAL 64.8 MG TABLET [6219]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 16571066701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$2.28
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$2.52
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$2.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.28
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.28
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENOBARBITAL 64.8 MG TABLET [6219]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 16571066701
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]
|
Facility
|
IP
|
$450.00
|
|
|
Service Code
|
HCPCS J2560
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$382.50 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Health Management Network Commercial |
$765.00
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$810.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: MDX Hawaii PPO |
$873.00
|
|
|
PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION [6221]
|
Facility
|
OP
|
$450.00
|
|
|
Service Code
|
HCPCS J2560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.36 |
| Max. Negotiated Rate |
$436.50 |
| Rate for Payer: AlohaCare Medicaid |
$225.00
|
| Rate for Payer: AlohaCare Medicaid |
$450.00
|
| Rate for Payer: AlohaCare Medicaid |
$68.00
|
| Rate for Payer: AlohaCare Medicare |
$684.00
|
| Rate for Payer: AlohaCare Medicare |
$103.36
|
| Rate for Payer: AlohaCare Medicare |
$342.00
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Devoted Health Medicare |
$756.00
|
| Rate for Payer: Devoted Health Medicare |
$378.00
|
| Rate for Payer: Devoted Health Medicare |
$114.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$27.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$27.36
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$27.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$342.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$684.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$103.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$27.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$855.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$129.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$427.50
|
| Rate for Payer: Health Management Network Commercial |
$115.60
|
| Rate for Payer: Health Management Network Commercial |
$382.50
|
| Rate for Payer: Health Management Network Commercial |
$765.00
|
| Rate for Payer: Humana Medicare |
$342.00
|
| Rate for Payer: Humana Medicare |
$103.36
|
| Rate for Payer: Humana Medicare |
$684.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$405.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$810.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$459.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$69.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$342.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$103.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$684.00
|
| Rate for Payer: MDX Hawaii PPO |
$873.00
|
| Rate for Payer: MDX Hawaii PPO |
$131.92
|
| Rate for Payer: MDX Hawaii PPO |
$436.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$342.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$684.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$103.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$684.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$103.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$342.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$81.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$270.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$540.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$103.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$684.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$342.00
|
| Rate for Payer: University Health Alliance Commercial |
$656.01
|
| Rate for Payer: University Health Alliance Commercial |
$328.00
|
| Rate for Payer: University Health Alliance Commercial |
$99.13
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 00536122858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
|
|
PHENOL 1.4 % MUCOSAL AEROSOL SPRAY [36976]
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00536122858
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$9.12
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$10.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$9.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.12
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.12
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
|
IP
|
$756.00
|
|
|
Service Code
|
HCPCS J2760
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$642.60 |
| Max. Negotiated Rate |
$733.32 |
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Health Management Network Commercial |
$642.60
|
| Rate for Payer: Health Management Network Commercial |
$749.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$680.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$793.80
|
| Rate for Payer: MDX Hawaii PPO |
$855.54
|
| Rate for Payer: MDX Hawaii PPO |
$733.32
|
|
|
PHENTOLAMINE 5 MG INJECTION SOLUTION [10947]
|
Facility
|
OP
|
$882.00
|
|
|
Service Code
|
HCPCS J2760
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$321.81 |
| Max. Negotiated Rate |
$855.54 |
| Rate for Payer: AlohaCare Medicaid |
$441.00
|
| Rate for Payer: AlohaCare Medicaid |
$378.00
|
| Rate for Payer: AlohaCare Medicare |
$670.32
|
| Rate for Payer: AlohaCare Medicare |
$574.56
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$453.60
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Devoted Health Medicare |
$635.04
|
| Rate for Payer: Devoted Health Medicare |
$740.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$436.51
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$436.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$321.81
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$321.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$574.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$670.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$436.51
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$436.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$718.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$837.90
|
| Rate for Payer: Health Management Network Commercial |
$642.60
|
| Rate for Payer: Health Management Network Commercial |
$749.70
|
| Rate for Payer: Humana Medicare |
$574.56
|
| Rate for Payer: Humana Medicare |
$670.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$793.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$680.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$385.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$574.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$670.32
|
| Rate for Payer: MDX Hawaii PPO |
$855.54
|
| Rate for Payer: MDX Hawaii PPO |
$733.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$574.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$670.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$574.56
|
| Rate for Payer: Ohana Health Plan Medicare |
$670.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$453.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$529.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$670.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$574.56
|
| Rate for Payer: University Health Alliance Commercial |
$551.05
|
| Rate for Payer: University Health Alliance Commercial |
$642.89
|
|
|
PHENYLEPHRINE 0.5 % NASAL SPRAY [6244]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00225080547
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
PHENYLEPHRINE 10 % EYE DROPS [19636]
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
NDC 70756061430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.00 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicare |
$114.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Devoted Health Medicare |
$126.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$114.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$114.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$114.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$114.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$114.00
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
|
|
PHENYLEPHRINE 10 % EYE DROPS [19636]
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
NDC 70756061430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$127.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
|
|
PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION [127358]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
HCPCS J2371
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Health Management Network Commercial |
$3.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: MDX Hawaii PPO |
$3.88
|
|
|
PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE [132408]
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2371
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
PHENYLEPHRINE 2.5 % EYE DROPS [6246]
|
Facility
|
OP
|
$338.00
|
|
|
Service Code
|
NDC 70756064935
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$327.86 |
| Rate for Payer: AlohaCare Medicaid |
$169.00
|
| Rate for Payer: AlohaCare Medicare |
$256.88
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Devoted Health Medicare |
$283.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$256.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$321.10
|
| Rate for Payer: Health Management Network Commercial |
$287.30
|
| Rate for Payer: Humana Medicare |
$256.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$304.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$256.88
|
| Rate for Payer: MDX Hawaii PPO |
$327.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$256.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$256.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$256.88
|
| Rate for Payer: University Health Alliance Commercial |
$246.37
|
|
|
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: Kaiser Permanente Commercial |
$304.20
|
| Rate for Payer: MDX Hawaii PPO |
$327.86
|
|
|
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: Kaiser Permanente Commercial |
$22.50
|
| 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 |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| 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: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [37993]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687027562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.50 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$19.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$21.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$19.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.00
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.00
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
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: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
|
|
PHENYTOIN 50 MG CHEWABLE TABLET [11018]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 51672414601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$1.52
|
| Rate for Payer: Cash Price |
$1.20
|
| 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 |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$1.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.52
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.52
|
| Rate for Payer: University Health Alliance Commercial |
$1.46
|
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
