|
PERSONA TIB STM 5 DEG SZ H, L
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS C1713
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$620.00 |
| Max. Negotiated Rate |
$1,940.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,000.00
|
| Rate for Payer: AlohaCare Medicare |
$620.00
|
| Rate for Payer: Cash Price |
$1,200.00
|
| Rate for Payer: Devoted Health Medicare |
$680.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$620.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,400.00
|
| Rate for Payer: Health Management Network Commercial |
$1,700.00
|
| Rate for Payer: Humana Medicare |
$620.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,800.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,020.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$620.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,940.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$620.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$620.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$620.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,120.00
|
|
|
PERSON TIB STM 5 DEG SZ H, R
|
Facility
|
IP
|
$2,600.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,456.00 |
| Max. Negotiated Rate |
$2,522.00 |
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,820.00
|
| Rate for Payer: Health Management Network Commercial |
$2,210.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,340.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,522.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,456.00
|
|
|
PERSON TIB STM 5 DEG SZ H, R
|
Facility
|
OP
|
$2,600.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$806.00 |
| Max. Negotiated Rate |
$2,522.00 |
| Rate for Payer: AlohaCare Medicaid |
$1,300.00
|
| Rate for Payer: AlohaCare Medicare |
$806.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Devoted Health Medicare |
$884.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$806.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,820.00
|
| Rate for Payer: Health Management Network Commercial |
$2,210.00
|
| Rate for Payer: Humana Medicare |
$806.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,340.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,326.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$806.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,522.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$806.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$806.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$806.00
|
| Rate for Payer: University Health Alliance Commercial |
$1,456.00
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [174456]
|
Facility
|
IP
|
$17,200.00
|
|
|
Service Code
|
HCPCS J9316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14,620.00 |
| Max. Negotiated Rate |
$16,684.00 |
| Rate for Payer: Cash Price |
$10,320.00
|
| Rate for Payer: Health Management Network Commercial |
$14,620.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$15,480.00
|
| Rate for Payer: MDX Hawaii PPO |
$16,684.00
|
|
|
PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN [174456]
|
Facility
|
OP
|
$17,200.00
|
|
|
Service Code
|
HCPCS J9316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.39 |
| Max. Negotiated Rate |
$16,684.00 |
| Rate for Payer: AlohaCare Medicaid |
$8,600.00
|
| Rate for Payer: AlohaCare Medicare |
$5,332.00
|
| Rate for Payer: Cash Price |
$10,320.00
|
| Rate for Payer: Cash Price |
$10,320.00
|
| Rate for Payer: Devoted Health Medicare |
$5,848.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$63.39
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$75.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,332.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$63.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$16,340.00
|
| Rate for Payer: Health Management Network Commercial |
$14,620.00
|
| Rate for Payer: Humana Medicare |
$5,332.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$15,480.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,772.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,332.00
|
| Rate for Payer: MDX Hawaii PPO |
$16,684.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,332.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,332.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$10,320.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,332.00
|
| Rate for Payer: University Health Alliance Commercial |
$12,537.08
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [116596]
|
Facility
|
OP
|
$11,459.00
|
|
|
Service Code
|
HCPCS J9306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.89 |
| Max. Negotiated Rate |
$11,115.23 |
| Rate for Payer: AlohaCare Medicaid |
$5,729.50
|
| Rate for Payer: AlohaCare Medicare |
$3,552.29
|
| Rate for Payer: Cash Price |
$6,875.40
|
| Rate for Payer: Cash Price |
$6,875.40
|
| Rate for Payer: Devoted Health Medicare |
$3,896.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.89
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$21.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,552.29
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$10,886.05
|
| Rate for Payer: Health Management Network Commercial |
$9,740.15
|
| Rate for Payer: Humana Medicare |
$3,552.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,313.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,844.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,552.29
|
| Rate for Payer: MDX Hawaii PPO |
$11,115.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,552.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,552.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,875.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,552.29
|
| Rate for Payer: University Health Alliance Commercial |
$8,352.47
|
|
|
PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [116596]
|
Facility
|
IP
|
$11,459.00
|
|
|
Service Code
|
HCPCS J9306
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,740.15 |
| Max. Negotiated Rate |
$11,115.23 |
| Rate for Payer: Cash Price |
$6,875.40
|
| Rate for Payer: Health Management Network Commercial |
$9,740.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,313.10
|
| Rate for Payer: MDX Hawaii PPO |
$11,115.23
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [174455]
|
Facility
|
OP
|
$11,633.00
|
|
|
Service Code
|
HCPCS J9316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.39 |
| Max. Negotiated Rate |
$11,284.01 |
| Rate for Payer: AlohaCare Medicaid |
$5,816.50
|
| Rate for Payer: AlohaCare Medicare |
$3,606.23
|
| Rate for Payer: Cash Price |
$6,979.80
|
| Rate for Payer: Cash Price |
$6,979.80
|
| Rate for Payer: Devoted Health Medicare |
$3,955.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$63.39
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$75.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,606.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$63.39
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,051.35
|
| Rate for Payer: Health Management Network Commercial |
$9,888.05
|
| Rate for Payer: Humana Medicare |
$3,606.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,469.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5,932.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,606.23
|
| Rate for Payer: MDX Hawaii PPO |
$11,284.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3,606.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,606.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6,979.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,606.23
|
| Rate for Payer: University Health Alliance Commercial |
$8,479.29
|
|
|
PERTUZUMAB 600 MG-TRASTUZUMAB 600 MG-HYALURONID-ZZXF/10 ML SUBCUT SOLN [174455]
|
Facility
|
IP
|
$11,633.00
|
|
|
Service Code
|
HCPCS J9316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9,888.05 |
| Max. Negotiated Rate |
$11,284.01 |
| Rate for Payer: Cash Price |
$6,979.80
|
| Rate for Payer: Health Management Network Commercial |
$9,888.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$10,469.70
|
| Rate for Payer: MDX Hawaii PPO |
$11,284.01
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
NDC 65162068110
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: AlohaCare Medicaid |
$5.00
|
| Rate for Payer: AlohaCare Medicare |
$3.10
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Devoted Health Medicare |
$3.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.50
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Humana Medicare |
$3.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.10
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.10
|
| Rate for Payer: University Health Alliance Commercial |
$7.29
|
|
|
PHENAZOPYRIDINE 100 MG TABLET [6193]
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
NDC 65162068110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$9.70 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Health Management Network Commercial |
$8.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.00
|
| Rate for Payer: MDX Hawaii PPO |
$9.70
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 65162068210
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: AlohaCare Medicaid |
$7.00
|
| Rate for Payer: AlohaCare Medicare |
$4.34
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Devoted Health Medicare |
$4.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.30
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Humana Medicare |
$4.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.34
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.34
|
| Rate for Payer: University Health Alliance Commercial |
$10.20
|
|
|
PHENAZOPYRIDINE 200 MG TABLET [6194]
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 65162068210
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$13.58 |
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Health Management Network Commercial |
$11.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.60
|
| Rate for Payer: MDX Hawaii PPO |
$13.58
|
|
|
PHENAZOPYRIDINE TABLETS (PYRIDIUM) 200 MG (TAKE HOME) [4080389]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
NDC 00004080177
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$4.65 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
PHENAZOPYRIDINE TABLETS (PYRIDIUM) 200 MG (TAKE HOME) [4080389]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
NDC 00004080177
|
|
Hospital Revenue Code
|
253
|
| 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
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 63739029410
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
PHENOBARBITAL 32.4 MG TABLET [6217]
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
NDC 00904657561
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: AlohaCare Medicaid |
$1.00
|
| Rate for Payer: AlohaCare Medicare |
$0.62
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Devoted Health Medicare |
$0.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1.90
|
| Rate for Payer: Health Management Network Commercial |
$1.70
|
| Rate for Payer: Humana Medicare |
$0.62
|
| Rate for Payer: Kaiser Permanente Commercial |
$1.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.02
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.62
|
| Rate for Payer: MDX Hawaii PPO |
$1.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.62
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.62
|
| 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
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 63739029410
|
|
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 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 64.8 MG TABLET [6219]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 16571066701
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: AlohaCare Medicaid |
$1.50
|
| Rate for Payer: AlohaCare Medicare |
$0.93
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Devoted Health Medicare |
$1.02
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$0.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2.85
|
| Rate for Payer: Health Management Network Commercial |
$2.55
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$0.93
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$0.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$0.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$0.93
|
| Rate for Payer: University Health Alliance Commercial |
$2.19
|
|
|
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 |
$279.00
|
| Rate for Payer: AlohaCare Medicare |
$42.16
|
| Rate for Payer: AlohaCare Medicare |
$139.50
|
| 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 |
$306.00
|
| Rate for Payer: Devoted Health Medicare |
$153.00
|
| Rate for Payer: Devoted Health Medicare |
$46.24
|
| 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 |
$139.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$279.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$42.16
|
| 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 |
$139.50
|
| Rate for Payer: Humana Medicare |
$42.16
|
| Rate for Payer: Humana Medicare |
$279.00
|
| 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 |
$139.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$42.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$279.00
|
| 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 |
$139.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$279.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$42.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$279.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$42.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$139.50
|
| 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 |
$42.16
|
| Rate for Payer: UnitedHealthcare Medicare |
$279.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$139.50
|
| 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
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 00536122858
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.72 |
| Max. Negotiated Rate |
$11.64 |
| Rate for Payer: AlohaCare Medicaid |
$6.00
|
| Rate for Payer: AlohaCare Medicare |
$3.72
|
| Rate for Payer: Cash Price |
$7.20
|
| Rate for Payer: Devoted Health Medicare |
$4.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3.72
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11.40
|
| Rate for Payer: Health Management Network Commercial |
$10.20
|
| Rate for Payer: Humana Medicare |
$3.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$10.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$6.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$3.72
|
| Rate for Payer: MDX Hawaii PPO |
$11.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$3.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$3.72
|
| Rate for Payer: UnitedHealthcare Medicare |
$3.72
|
| Rate for Payer: University Health Alliance Commercial |
$8.75
|
|
|
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
|
|
