|
.Phencyclidine, Ur Confrm FSI
|
Facility
|
IP
|
$220.00
|
|
|
Service Code
|
HCPCS 83992
|
| Hospital Charge Code |
8728229
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$187.00 |
| Max. Negotiated Rate |
$213.40 |
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
|
|
.Phencyclidine, Ur Confrm FSI
|
Facility
|
OP
|
$220.00
|
|
|
Service Code
|
HCPCS 83992
|
| Hospital Charge Code |
8728229
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$213.40 |
| Rate for Payer: AlohaCare Medicaid |
$110.00
|
| Rate for Payer: AlohaCare Medicare |
$110.00
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Cash Price |
$143.00
|
| Rate for Payer: Devoted Health Medicare |
$121.00
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$20.31
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$209.00
|
| Rate for Payer: Health Management Network Commercial |
$187.00
|
| Rate for Payer: Humana Medicare |
$110.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$198.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$112.20
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.00
|
| Rate for Payer: MDX Hawaii PPO |
$213.40
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.00
|
| Rate for Payer: University Health Alliance Commercial |
$38.00
|
|
|
Phencyclidine, Urine Screen FSI
|
Facility
|
OP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228907
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.89 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: AlohaCare Medicaid |
$692.00
|
| Rate for Payer: AlohaCare Medicare |
$692.00
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Devoted Health Medicare |
$761.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$59.38
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$77.67
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$692.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$59.38
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$62.14
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Humana Medicare |
$692.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$705.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$692.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$692.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$692.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$47.89
|
| Rate for Payer: UnitedHealthcare Medicare |
$692.00
|
| Rate for Payer: University Health Alliance Commercial |
$147.65
|
|
|
Phencyclidine, Urine Screen FSI
|
Facility
|
IP
|
$1,384.00
|
|
|
Service Code
|
HCPCS 80307
|
| Hospital Charge Code |
8228907
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1,176.40 |
| Max. Negotiated Rate |
$1,342.48 |
| Rate for Payer: Cash Price |
$899.60
|
| Rate for Payer: Health Management Network Commercial |
$1,176.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,245.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,342.48
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
OP
|
$106.04
|
|
|
Service Code
|
NDC 71914016204
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.02 |
| Max. Negotiated Rate |
$102.86 |
| Rate for Payer: AlohaCare Medicaid |
$53.02
|
| Rate for Payer: AlohaCare Medicare |
$53.02
|
| Rate for Payer: Cash Price |
$68.93
|
| Rate for Payer: Devoted Health Medicare |
$58.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$53.02
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.74
|
| Rate for Payer: Health Management Network Commercial |
$90.13
|
| Rate for Payer: Humana Medicare |
$53.02
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.44
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$53.02
|
| Rate for Payer: MDX Hawaii PPO |
$102.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$53.02
|
| Rate for Payer: Ohana Health Plan Medicare |
$53.02
|
| Rate for Payer: UnitedHealthcare Medicaid |
$63.62
|
| Rate for Payer: UnitedHealthcare Medicare |
$53.02
|
| Rate for Payer: University Health Alliance Commercial |
$77.29
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
OP
|
$154.18
|
|
|
Service Code
|
NDC 50742066604
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.09 |
| Max. Negotiated Rate |
$149.55 |
| Rate for Payer: AlohaCare Medicaid |
$77.09
|
| Rate for Payer: AlohaCare Medicare |
$77.09
|
| Rate for Payer: Cash Price |
$100.22
|
| Rate for Payer: Devoted Health Medicare |
$84.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$77.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$146.47
|
| Rate for Payer: Health Management Network Commercial |
$131.05
|
| Rate for Payer: Humana Medicare |
$77.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.76
|
| Rate for Payer: Kaiser Permanente Medicaid |
$78.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$77.09
|
| Rate for Payer: MDX Hawaii PPO |
$149.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$77.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$77.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$92.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$77.09
|
| Rate for Payer: University Health Alliance Commercial |
$112.38
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
IP
|
$169.31
|
|
|
Service Code
|
NDC 59212042304
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.91 |
| Max. Negotiated Rate |
$164.23 |
| Rate for Payer: Cash Price |
$110.05
|
| Rate for Payer: Health Management Network Commercial |
$143.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.38
|
| Rate for Payer: MDX Hawaii PPO |
$164.23
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
OP
|
$169.31
|
|
|
Service Code
|
NDC 59212042304
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.66 |
| Max. Negotiated Rate |
$164.23 |
| Rate for Payer: AlohaCare Medicaid |
$84.66
|
| Rate for Payer: AlohaCare Medicare |
$84.66
|
| Rate for Payer: Cash Price |
$110.05
|
| Rate for Payer: Devoted Health Medicare |
$93.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$84.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$160.84
|
| Rate for Payer: Health Management Network Commercial |
$143.91
|
| Rate for Payer: Humana Medicare |
$84.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$152.38
|
| Rate for Payer: Kaiser Permanente Medicaid |
$86.35
|
| Rate for Payer: Kaiser Permanente Medicare |
$84.66
|
| Rate for Payer: MDX Hawaii PPO |
$164.23
|
| Rate for Payer: Ohana Health Plan Medicaid |
$84.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$84.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$101.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$84.66
|
| Rate for Payer: University Health Alliance Commercial |
$123.41
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
IP
|
$106.04
|
|
|
Service Code
|
NDC 71914016204
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$90.13 |
| Max. Negotiated Rate |
$102.86 |
| Rate for Payer: Cash Price |
$68.93
|
| Rate for Payer: Health Management Network Commercial |
$90.13
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.44
|
| Rate for Payer: MDX Hawaii PPO |
$102.86
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
IP
|
$131.52
|
|
|
Service Code
|
NDC 72768901104
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$111.79 |
| Max. Negotiated Rate |
$127.57 |
| Rate for Payer: Cash Price |
$85.49
|
| Rate for Payer: Health Management Network Commercial |
$111.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.37
|
| Rate for Payer: MDX Hawaii PPO |
$127.57
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
IP
|
$154.18
|
|
|
Service Code
|
NDC 50742066604
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.05 |
| Max. Negotiated Rate |
$149.55 |
| Rate for Payer: Cash Price |
$100.22
|
| Rate for Payer: Health Management Network Commercial |
$131.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$138.76
|
| Rate for Payer: MDX Hawaii PPO |
$149.55
|
|
|
phenobarb-belladonna 32.4mg/10mL [HHSC]
|
Facility
|
OP
|
$131.52
|
|
|
Service Code
|
NDC 72768901104
|
| Hospital Charge Code |
2500086
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.76 |
| Max. Negotiated Rate |
$127.57 |
| Rate for Payer: AlohaCare Medicaid |
$65.76
|
| Rate for Payer: AlohaCare Medicare |
$65.76
|
| Rate for Payer: Cash Price |
$85.49
|
| Rate for Payer: Devoted Health Medicare |
$72.34
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$65.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$124.94
|
| Rate for Payer: Health Management Network Commercial |
$111.79
|
| Rate for Payer: Humana Medicare |
$65.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.08
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.76
|
| Rate for Payer: MDX Hawaii PPO |
$127.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$65.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$65.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$78.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$65.76
|
| Rate for Payer: University Health Alliance Commercial |
$95.86
|
|
|
PHENobarbital 130 mg/ml vial [HHSC]
|
Facility
|
OP
|
$336.92
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
2500646
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.36 |
| Max. Negotiated Rate |
$326.81 |
| Rate for Payer: AlohaCare Medicaid |
$168.46
|
| Rate for Payer: AlohaCare Medicaid |
$168.47
|
| Rate for Payer: AlohaCare Medicare |
$168.47
|
| Rate for Payer: AlohaCare Medicare |
$168.46
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Devoted Health Medicare |
$185.31
|
| Rate for Payer: Devoted Health Medicare |
$185.31
|
| 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 |
$168.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$168.46
|
| 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 |
$320.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$320.08
|
| Rate for Payer: Health Management Network Commercial |
$286.39
|
| Rate for Payer: Health Management Network Commercial |
$286.38
|
| Rate for Payer: Humana Medicare |
$168.46
|
| Rate for Payer: Humana Medicare |
$168.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$171.83
|
| Rate for Payer: Kaiser Permanente Medicaid |
$171.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$168.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$168.47
|
| Rate for Payer: MDX Hawaii PPO |
$326.81
|
| Rate for Payer: MDX Hawaii PPO |
$326.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$168.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$168.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$168.46
|
| Rate for Payer: Ohana Health Plan Medicare |
$168.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$202.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$202.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$168.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$168.47
|
| Rate for Payer: University Health Alliance Commercial |
$245.58
|
| Rate for Payer: University Health Alliance Commercial |
$245.59
|
|
|
PHENobarbital 130 mg/ml vial [HHSC]
|
Facility
|
IP
|
$336.92
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
2500646
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$286.38 |
| Max. Negotiated Rate |
$326.81 |
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Cash Price |
$219.00
|
| Rate for Payer: Health Management Network Commercial |
$286.38
|
| Rate for Payer: Health Management Network Commercial |
$286.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.24
|
| Rate for Payer: MDX Hawaii PPO |
$326.82
|
| Rate for Payer: MDX Hawaii PPO |
$326.81
|
|
|
PHENobarbital 32.4 mg tablet [HHSC]
|
Facility
|
IP
|
$4.71
|
|
|
Service Code
|
NDC 63739020110
|
| Hospital Charge Code |
2500648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.00 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Health Management Network Commercial |
$4.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.24
|
| Rate for Payer: MDX Hawaii PPO |
$4.57
|
|
|
PHENobarbital 32.4 mg tablet [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
2500648
|
|
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
|
|
|
PHENobarbital 32.4 mg tablet [HHSC]
|
Facility
|
OP
|
$4.71
|
|
|
Service Code
|
NDC 63739020110
|
| Hospital Charge Code |
2500648
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: AlohaCare Medicaid |
$2.35
|
| Rate for Payer: AlohaCare Medicare |
$2.35
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Devoted Health Medicare |
$2.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.35
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.47
|
| Rate for Payer: Health Management Network Commercial |
$4.00
|
| Rate for Payer: Humana Medicare |
$2.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2.40
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.35
|
| Rate for Payer: MDX Hawaii PPO |
$4.57
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.35
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.35
|
| Rate for Payer: University Health Alliance Commercial |
$3.43
|
|
|
PHENobarbital 32.4 mg tablet [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 00904657561
|
| Hospital Charge Code |
2500648
|
|
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
|
|
|
Phenobarbital REF
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
8159985
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$113.05 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
|
|
Phenobarbital REF
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
HCPCS 80184
|
| Hospital Charge Code |
8159985
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: AlohaCare Medicaid |
$66.50
|
| Rate for Payer: AlohaCare Medicare |
$66.50
|
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Cash Price |
$86.45
|
| Rate for Payer: Devoted Health Medicare |
$73.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$15.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$19.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.62
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$15.30
|
| Rate for Payer: Health Management Network Commercial |
$113.05
|
| Rate for Payer: Humana Medicare |
$66.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.83
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.50
|
| Rate for Payer: MDX Hawaii PPO |
$129.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.50
|
| Rate for Payer: University Health Alliance Commercial |
$29.62
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
OP
|
$13.90
|
|
|
Service Code
|
NDC 00904630521
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.95 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: AlohaCare Medicaid |
$6.95
|
| Rate for Payer: AlohaCare Medicare |
$6.95
|
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Devoted Health Medicare |
$7.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$6.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.21
|
| Rate for Payer: Health Management Network Commercial |
$11.81
|
| Rate for Payer: Humana Medicare |
$6.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$6.95
|
| Rate for Payer: MDX Hawaii PPO |
$13.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$6.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$6.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$6.95
|
| Rate for Payer: University Health Alliance Commercial |
$10.13
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
IP
|
$14.46
|
|
|
Service Code
|
NDC 46122026530
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.29 |
| Max. Negotiated Rate |
$14.03 |
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Health Management Network Commercial |
$12.29
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.01
|
| Rate for Payer: MDX Hawaii PPO |
$14.03
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
IP
|
$13.90
|
|
|
Service Code
|
NDC 00904630521
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.81 |
| Max. Negotiated Rate |
$13.48 |
| Rate for Payer: Cash Price |
$9.04
|
| Rate for Payer: Health Management Network Commercial |
$11.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$12.51
|
| Rate for Payer: MDX Hawaii PPO |
$13.48
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
OP
|
$14.46
|
|
|
Service Code
|
NDC 46122026530
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$14.03 |
| Rate for Payer: AlohaCare Medicaid |
$7.23
|
| Rate for Payer: AlohaCare Medicare |
$7.23
|
| Rate for Payer: Cash Price |
$9.40
|
| Rate for Payer: Devoted Health Medicare |
$7.95
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.74
|
| Rate for Payer: Health Management Network Commercial |
$12.29
|
| Rate for Payer: Humana Medicare |
$7.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.23
|
| Rate for Payer: MDX Hawaii PPO |
$14.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.23
|
| Rate for Payer: University Health Alliance Commercial |
$10.54
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
IP
|
$25.30
|
|
|
Service Code
|
NDC 78112001103
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$24.54 |
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Health Management Network Commercial |
$21.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.77
|
| Rate for Payer: MDX Hawaii PPO |
$24.54
|
|
