|
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 |
$273.42 |
| Max. Negotiated Rate |
$855.54 |
| Rate for Payer: AlohaCare Medicaid |
$441.00
|
| Rate for Payer: AlohaCare Medicaid |
$378.00
|
| Rate for Payer: AlohaCare Medicare |
$273.42
|
| Rate for Payer: AlohaCare Medicare |
$234.36
|
| 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 |
$257.04
|
| Rate for Payer: Devoted Health Medicare |
$299.88
|
| 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 |
$234.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.42
|
| 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 |
$234.36
|
| Rate for Payer: Humana Medicare |
$273.42
|
| 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 |
$234.36
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.42
|
| Rate for Payer: MDX Hawaii PPO |
$855.54
|
| Rate for Payer: MDX Hawaii PPO |
$733.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$234.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$273.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$234.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$273.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$453.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$529.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$234.36
|
| 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
|
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 % EYE DROPS [19636]
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
NDC 70756061430
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$145.50 |
| Rate for Payer: AlohaCare Medicaid |
$75.00
|
| Rate for Payer: AlohaCare Medicare |
$46.50
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Devoted Health Medicare |
$51.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$46.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$142.50
|
| Rate for Payer: Health Management Network Commercial |
$127.50
|
| Rate for Payer: Humana Medicare |
$46.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$76.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$46.50
|
| Rate for Payer: MDX Hawaii PPO |
$145.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$46.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$46.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$46.50
|
| Rate for Payer: University Health Alliance Commercial |
$109.33
|
|
|
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 |
$104.78 |
| Max. Negotiated Rate |
$327.86 |
| Rate for Payer: AlohaCare Medicaid |
$169.00
|
| Rate for Payer: AlohaCare Medicare |
$104.78
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Devoted Health Medicare |
$114.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$104.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$321.10
|
| Rate for Payer: Health Management Network Commercial |
$287.30
|
| Rate for Payer: Humana Medicare |
$104.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$304.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$172.38
|
| Rate for Payer: Kaiser Permanente Medicare |
$104.78
|
| Rate for Payer: MDX Hawaii PPO |
$327.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$104.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$104.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$104.78
|
| 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 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
|
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 60687027562
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$7.75
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$8.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$7.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.75
|
| Rate for Payer: University Health Alliance Commercial |
$18.22
|
|
|
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION [37993]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
NDC 60687027566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.75 |
| Max. Negotiated Rate |
$24.25 |
| Rate for Payer: AlohaCare Medicaid |
$12.50
|
| Rate for Payer: AlohaCare Medicare |
$7.75
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Devoted Health Medicare |
$8.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.75
|
| Rate for Payer: Health Management Network Commercial |
$21.25
|
| Rate for Payer: Humana Medicare |
$7.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.75
|
| Rate for Payer: MDX Hawaii PPO |
$24.25
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.75
|
| 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 |
$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
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 51672411101
|
|
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
|
|
|
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
|
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| Rate for Payer: MDX Hawaii PPO |
$2.91
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE [6257]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 65862069201
|
|
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
|
|
|
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: Kaiser Permanente Commercial |
$2.70
|
| 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 |
$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
|
|
|
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: Kaiser Permanente Commercial |
$6.30
|
| 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 |
$2.17 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| 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 |
$2.17 |
| Max. Negotiated Rate |
$6.79 |
| Rate for Payer: AlohaCare Medicaid |
$3.50
|
| Rate for Payer: AlohaCare Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$4.20
|
| Rate for Payer: Devoted Health Medicare |
$2.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6.65
|
| Rate for Payer: Health Management Network Commercial |
$5.95
|
| Rate for Payer: Humana Medicare |
$2.17
|
| Rate for Payer: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$3.57
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.17
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.17
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.17
|
| Rate for Payer: University Health Alliance Commercial |
$5.10
|
|
|
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: Kaiser Permanente Commercial |
$6.30
|
| Rate for Payer: MDX Hawaii PPO |
$6.79
|
|
