|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
OP
|
$31.08
|
|
|
Service Code
|
NDC 46122074876
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.54 |
| Max. Negotiated Rate |
$30.15 |
| Rate for Payer: AlohaCare Medicaid |
$15.54
|
| Rate for Payer: AlohaCare Medicare |
$15.54
|
| Rate for Payer: Cash Price |
$20.20
|
| Rate for Payer: Devoted Health Medicare |
$17.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.53
|
| Rate for Payer: Health Management Network Commercial |
$26.42
|
| Rate for Payer: Humana Medicare |
$15.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.97
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.85
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.54
|
| Rate for Payer: MDX Hawaii PPO |
$30.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.65
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.54
|
| Rate for Payer: University Health Alliance Commercial |
$22.65
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
OP
|
$25.30
|
|
|
Service Code
|
NDC 78112001103
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.65 |
| Max. Negotiated Rate |
$24.54 |
| Rate for Payer: AlohaCare Medicaid |
$12.65
|
| Rate for Payer: AlohaCare Medicare |
$12.65
|
| Rate for Payer: Cash Price |
$16.44
|
| Rate for Payer: Devoted Health Medicare |
$13.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.65
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$24.04
|
| Rate for Payer: Health Management Network Commercial |
$21.50
|
| Rate for Payer: Humana Medicare |
$12.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.65
|
| Rate for Payer: MDX Hawaii PPO |
$24.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.65
|
| Rate for Payer: University Health Alliance Commercial |
$18.44
|
|
|
phenol 1.4% throat spray 177mL [HHSC]
|
Facility
|
IP
|
$31.08
|
|
|
Service Code
|
NDC 46122074876
|
| Hospital Charge Code |
2500649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.42 |
| Max. Negotiated Rate |
$30.15 |
| Rate for Payer: Cash Price |
$20.20
|
| Rate for Payer: Health Management Network Commercial |
$26.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.97
|
| Rate for Payer: MDX Hawaii PPO |
$30.15
|
|
|
phenylephrine 10 mg/ml vial [HHSC]
|
Facility
|
IP
|
$15.29
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
2500651
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cash Price |
$15.51
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cash Price |
$15.92
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$17.70
|
| Rate for Payer: Health Management Network Commercial |
$6.81
|
| Rate for Payer: Health Management Network Commercial |
$18.15
|
| Rate for Payer: Health Management Network Commercial |
$13.00
|
| Rate for Payer: Health Management Network Commercial |
$20.28
|
| Rate for Payer: Health Management Network Commercial |
$20.82
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.21
|
| Rate for Payer: MDX Hawaii PPO |
$23.14
|
| Rate for Payer: MDX Hawaii PPO |
$14.83
|
| Rate for Payer: MDX Hawaii PPO |
$20.20
|
| Rate for Payer: MDX Hawaii PPO |
$20.71
|
| Rate for Payer: MDX Hawaii PPO |
$23.76
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$7.77
|
|
|
phenylephrine 10 mg/ml vial [HHSC]
|
Facility
|
OP
|
$20.82
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
2500651
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$20.20 |
| Rate for Payer: AlohaCare Medicaid |
$10.41
|
| Rate for Payer: AlohaCare Medicaid |
$4.00
|
| Rate for Payer: AlohaCare Medicaid |
$7.64
|
| Rate for Payer: AlohaCare Medicaid |
$11.93
|
| Rate for Payer: AlohaCare Medicaid |
$10.68
|
| Rate for Payer: AlohaCare Medicaid |
$12.24
|
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$12.24
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$4.00
|
| Rate for Payer: AlohaCare Medicare |
$10.41
|
| Rate for Payer: AlohaCare Medicare |
$11.93
|
| Rate for Payer: AlohaCare Medicare |
$7.64
|
| Rate for Payer: AlohaCare Medicare |
$10.68
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$15.51
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cash Price |
$13.53
|
| Rate for Payer: Cash Price |
$9.94
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cash Price |
$5.21
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$15.92
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cash Price |
$15.92
|
| Rate for Payer: Cash Price |
$15.51
|
| Rate for Payer: Devoted Health Medicare |
$4.41
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$13.47
|
| Rate for Payer: Devoted Health Medicare |
$13.12
|
| Rate for Payer: Devoted Health Medicare |
$8.41
|
| Rate for Payer: Devoted Health Medicare |
$11.74
|
| Rate for Payer: Devoted Health Medicare |
$11.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.68
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11.93
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$10.41
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$12.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.01
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$19.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$22.67
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$23.27
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7.61
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$20.82
|
| Rate for Payer: Health Management Network Commercial |
$6.81
|
| Rate for Payer: Health Management Network Commercial |
$20.28
|
| Rate for Payer: Health Management Network Commercial |
$17.70
|
| Rate for Payer: Health Management Network Commercial |
$13.00
|
| Rate for Payer: Health Management Network Commercial |
$18.15
|
| Rate for Payer: Humana Medicare |
$11.93
|
| Rate for Payer: Humana Medicare |
$4.00
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$10.41
|
| Rate for Payer: Humana Medicare |
$7.64
|
| Rate for Payer: Humana Medicare |
$12.24
|
| Rate for Payer: Humana Medicare |
$10.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$18.74
|
| Rate for Payer: Kaiser Permanente Commercial |
$21.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$22.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.76
|
| Rate for Payer: Kaiser Permanente Commercial |
$7.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$19.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.89
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$12.49
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$10.62
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.09
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$11.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$10.41
|
| Rate for Payer: Kaiser Permanente Medicare |
$12.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$7.64
|
| Rate for Payer: MDX Hawaii PPO |
$14.83
|
| Rate for Payer: MDX Hawaii PPO |
$7.77
|
| Rate for Payer: MDX Hawaii PPO |
$20.71
|
| Rate for Payer: MDX Hawaii PPO |
$23.14
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$23.76
|
| Rate for Payer: MDX Hawaii PPO |
$20.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$12.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$10.41
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$7.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$12.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$10.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$11.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$11.93
|
| Rate for Payer: UnitedHealthcare Medicare |
$7.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$12.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$10.41
|
| Rate for Payer: University Health Alliance Commercial |
$17.85
|
| Rate for Payer: University Health Alliance Commercial |
$15.56
|
| Rate for Payer: University Health Alliance Commercial |
$11.14
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$17.39
|
| Rate for Payer: University Health Alliance Commercial |
$15.18
|
| Rate for Payer: University Health Alliance Commercial |
$5.84
|
|
|
phenylephrine 2.5% ophth drops 2ml [HHSC]
|
Facility
|
OP
|
$187.98
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
2500654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$93.99 |
| Max. Negotiated Rate |
$182.34 |
| Rate for Payer: AlohaCare Medicaid |
$93.99
|
| Rate for Payer: AlohaCare Medicare |
$93.99
|
| Rate for Payer: Cash Price |
$122.19
|
| Rate for Payer: Devoted Health Medicare |
$103.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$93.99
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$178.58
|
| Rate for Payer: Health Management Network Commercial |
$159.78
|
| Rate for Payer: Humana Medicare |
$93.99
|
| Rate for Payer: Kaiser Permanente Commercial |
$169.18
|
| Rate for Payer: Kaiser Permanente Medicaid |
$95.87
|
| Rate for Payer: Kaiser Permanente Medicare |
$93.99
|
| Rate for Payer: MDX Hawaii PPO |
$182.34
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.99
|
| Rate for Payer: Ohana Health Plan Medicare |
$93.99
|
| Rate for Payer: UnitedHealthcare Medicaid |
$112.79
|
| Rate for Payer: UnitedHealthcare Medicare |
$93.99
|
| Rate for Payer: University Health Alliance Commercial |
$137.02
|
|
|
phenylephrine 2.5% ophth drops 2ml [HHSC]
|
Facility
|
IP
|
$187.98
|
|
|
Service Code
|
NDC 70756062925
|
| Hospital Charge Code |
2500654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.78 |
| Max. Negotiated Rate |
$182.34 |
| Rate for Payer: Cash Price |
$122.19
|
| Rate for Payer: Health Management Network Commercial |
$159.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$169.18
|
| Rate for Payer: MDX Hawaii PPO |
$182.34
|
|
|
phenylephrine 2.5% ophth drops 2ml [HHSC]
|
Facility
|
IP
|
$110.86
|
|
|
Service Code
|
NDC 00065034905
|
| Hospital Charge Code |
2500654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$94.23 |
| Max. Negotiated Rate |
$107.53 |
| Rate for Payer: Cash Price |
$72.06
|
| Rate for Payer: Health Management Network Commercial |
$94.23
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.77
|
| Rate for Payer: MDX Hawaii PPO |
$107.53
|
|
|
phenylephrine 2.5% ophth drops 2ml [HHSC]
|
Facility
|
OP
|
$110.86
|
|
|
Service Code
|
NDC 00065034905
|
| Hospital Charge Code |
2500654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.43 |
| Max. Negotiated Rate |
$107.53 |
| Rate for Payer: AlohaCare Medicaid |
$55.43
|
| Rate for Payer: AlohaCare Medicare |
$55.43
|
| Rate for Payer: Cash Price |
$72.06
|
| Rate for Payer: Devoted Health Medicare |
$60.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.43
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$105.32
|
| Rate for Payer: Health Management Network Commercial |
$94.23
|
| Rate for Payer: Humana Medicare |
$55.43
|
| Rate for Payer: Kaiser Permanente Commercial |
$99.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.43
|
| Rate for Payer: MDX Hawaii PPO |
$107.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.43
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.43
|
| Rate for Payer: University Health Alliance Commercial |
$80.81
|
|
|
phenylephrine 500 mcg/5 mL (PF) amp [HHSC]
|
Facility
|
OP
|
$38.90
|
|
|
Service Code
|
HCPCS J2372
|
| Hospital Charge Code |
2501095
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$37.73 |
| Rate for Payer: AlohaCare Medicaid |
$19.45
|
| Rate for Payer: AlohaCare Medicare |
$19.45
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Devoted Health Medicare |
$21.39
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.17
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$19.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.17
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.95
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Humana Medicare |
$19.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: Kaiser Permanente Medicaid |
$19.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$19.45
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$19.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$19.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$23.34
|
| Rate for Payer: UnitedHealthcare Medicare |
$19.45
|
| Rate for Payer: University Health Alliance Commercial |
$28.35
|
|
|
phenylephrine 500 mcg/5 mL (PF) amp [HHSC]
|
Facility
|
IP
|
$38.90
|
|
|
Service Code
|
HCPCS J2372
|
| Hospital Charge Code |
2501095
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.06 |
| Max. Negotiated Rate |
$37.73 |
| Rate for Payer: Cash Price |
$25.28
|
| Rate for Payer: Health Management Network Commercial |
$33.06
|
| Rate for Payer: Kaiser Permanente Commercial |
$35.01
|
| Rate for Payer: MDX Hawaii PPO |
$37.73
|
|
|
phenytoin 100 mg/4 mL U/D oral susp [HHSC]
|
Facility
|
IP
|
$48.83
|
|
|
Service Code
|
NDC 60687027566
|
| Hospital Charge Code |
2501166
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.51 |
| Max. Negotiated Rate |
$47.37 |
| Rate for Payer: Cash Price |
$31.74
|
| Rate for Payer: Health Management Network Commercial |
$41.51
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.95
|
| Rate for Payer: MDX Hawaii PPO |
$47.37
|
|
|
phenytoin 100 mg/4 mL U/D oral susp [HHSC]
|
Facility
|
OP
|
$48.83
|
|
|
Service Code
|
NDC 60687027566
|
| Hospital Charge Code |
2501166
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.41 |
| Max. Negotiated Rate |
$47.37 |
| Rate for Payer: AlohaCare Medicaid |
$24.41
|
| Rate for Payer: AlohaCare Medicare |
$24.41
|
| Rate for Payer: Cash Price |
$31.74
|
| Rate for Payer: Devoted Health Medicare |
$26.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$24.41
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.39
|
| Rate for Payer: Health Management Network Commercial |
$41.51
|
| Rate for Payer: Humana Medicare |
$24.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$43.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$24.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$24.41
|
| Rate for Payer: MDX Hawaii PPO |
$47.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$24.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$29.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$24.41
|
| Rate for Payer: University Health Alliance Commercial |
$35.59
|
|
|
phenytoin 125 mg/5 mL 120ml [HHSC]
|
Facility
|
IP
|
$96.39
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
2500657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.93 |
| Max. Negotiated Rate |
$93.50 |
| Rate for Payer: Cash Price |
$62.65
|
| Rate for Payer: Health Management Network Commercial |
$81.93
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.75
|
| Rate for Payer: MDX Hawaii PPO |
$93.50
|
|
|
phenytoin 125 mg/5 mL 120ml [HHSC]
|
Facility
|
OP
|
$442.31
|
|
|
Service Code
|
NDC 00071221420
|
| Hospital Charge Code |
2500657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$221.16 |
| Max. Negotiated Rate |
$429.04 |
| Rate for Payer: AlohaCare Medicaid |
$221.16
|
| Rate for Payer: AlohaCare Medicare |
$221.16
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Devoted Health Medicare |
$243.27
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$221.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$420.19
|
| Rate for Payer: Health Management Network Commercial |
$375.96
|
| Rate for Payer: Humana Medicare |
$221.16
|
| Rate for Payer: Kaiser Permanente Commercial |
$398.08
|
| Rate for Payer: Kaiser Permanente Medicaid |
$225.58
|
| Rate for Payer: Kaiser Permanente Medicare |
$221.16
|
| Rate for Payer: MDX Hawaii PPO |
$429.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$221.16
|
| Rate for Payer: Ohana Health Plan Medicare |
$221.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$265.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$221.16
|
| Rate for Payer: University Health Alliance Commercial |
$322.40
|
|
|
phenytoin 125 mg/5 mL 120ml [HHSC]
|
Facility
|
IP
|
$442.31
|
|
|
Service Code
|
NDC 00071221420
|
| Hospital Charge Code |
2500657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$375.96 |
| Max. Negotiated Rate |
$429.04 |
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Health Management Network Commercial |
$375.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$398.08
|
| Rate for Payer: MDX Hawaii PPO |
$429.04
|
|
|
phenytoin 125 mg/5 mL 120ml [HHSC]
|
Facility
|
OP
|
$96.39
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
2500657
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.20 |
| Max. Negotiated Rate |
$93.50 |
| Rate for Payer: AlohaCare Medicaid |
$48.20
|
| Rate for Payer: AlohaCare Medicare |
$48.20
|
| Rate for Payer: Cash Price |
$62.65
|
| Rate for Payer: Devoted Health Medicare |
$53.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$48.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.57
|
| Rate for Payer: Health Management Network Commercial |
$81.93
|
| Rate for Payer: Humana Medicare |
$48.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$86.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$49.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$48.20
|
| Rate for Payer: MDX Hawaii PPO |
$93.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$48.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$48.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$48.20
|
| Rate for Payer: University Health Alliance Commercial |
$70.26
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 51672411101
|
| Hospital Charge Code |
2500656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: AlohaCare Medicaid |
$1.78
|
| Rate for Payer: AlohaCare Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Devoted Health Medicare |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$3.03
|
| Rate for Payer: Humana Medicare |
$1.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.78
|
| Rate for Payer: MDX Hawaii PPO |
$3.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.78
|
| Rate for Payer: University Health Alliance Commercial |
$2.59
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
NDC 68084037601
|
| Hospital Charge Code |
2500656
|
|
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
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 65162021210
|
| Hospital Charge Code |
2500656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: AlohaCare Medicaid |
$1.78
|
| Rate for Payer: AlohaCare Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Devoted Health Medicare |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$3.03
|
| Rate for Payer: Humana Medicare |
$1.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.78
|
| Rate for Payer: MDX Hawaii PPO |
$3.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.78
|
| Rate for Payer: University Health Alliance Commercial |
$2.59
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 65862069201
|
| Hospital Charge Code |
2500656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: AlohaCare Medicaid |
$1.78
|
| Rate for Payer: AlohaCare Medicare |
$1.78
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Devoted Health Medicare |
$1.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.38
|
| Rate for Payer: Health Management Network Commercial |
$3.03
|
| Rate for Payer: Humana Medicare |
$1.78
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$1.78
|
| Rate for Payer: MDX Hawaii PPO |
$3.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$1.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$1.78
|
| Rate for Payer: University Health Alliance Commercial |
$2.59
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
OP
|
$10.41
|
|
|
Service Code
|
NDC 60687084101
|
| Hospital Charge Code |
2500656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: AlohaCare Medicaid |
$5.21
|
| Rate for Payer: AlohaCare Medicare |
$5.21
|
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Devoted Health Medicare |
$5.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9.89
|
| Rate for Payer: Health Management Network Commercial |
$8.85
|
| Rate for Payer: Humana Medicare |
$5.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.37
|
| Rate for Payer: Kaiser Permanente Medicaid |
$5.31
|
| Rate for Payer: Kaiser Permanente Medicare |
$5.21
|
| Rate for Payer: MDX Hawaii PPO |
$10.10
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$5.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$5.21
|
| Rate for Payer: University Health Alliance Commercial |
$7.59
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
IP
|
$10.41
|
|
|
Service Code
|
NDC 60687084101
|
| Hospital Charge Code |
2500656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.85 |
| Max. Negotiated Rate |
$10.10 |
| Rate for Payer: Cash Price |
$6.77
|
| Rate for Payer: Health Management Network Commercial |
$8.85
|
| Rate for Payer: Kaiser Permanente Commercial |
$9.37
|
| Rate for Payer: MDX Hawaii PPO |
$10.10
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 65862069201
|
| Hospital Charge Code |
2500656
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Health Management Network Commercial |
$3.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$3.20
|
| Rate for Payer: MDX Hawaii PPO |
$3.45
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
NDC 68084037601
|
| Hospital Charge Code |
2500656
|
|
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
|
|
