|
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
|
|
|
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
|
|
|
phenytoin ER 100 mg capsule [HHSC]
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 65162021210
|
| 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
|
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
|
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
|
$3.56
|
|
|
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
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 51672411101
|
| 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
|
$3.56
|
|
|
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
|
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
|
$3.00
|
|
|
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 FSI
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
8118012
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$128.35 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: Cash Price |
$98.15
|
| Rate for Payer: Health Management Network Commercial |
$128.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.90
|
| Rate for Payer: MDX Hawaii PPO |
$146.47
|
|
|
Phenytoin FSI
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
8118012
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$146.47 |
| Rate for Payer: AlohaCare Medicaid |
$75.50
|
| Rate for Payer: AlohaCare Medicare |
$75.50
|
| Rate for Payer: Cash Price |
$98.15
|
| Rate for Payer: Cash Price |
$98.15
|
| Rate for Payer: Devoted Health Medicare |
$83.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$18.32
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$16.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$75.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$19.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$13.25
|
| Rate for Payer: Health Management Network Commercial |
$128.35
|
| Rate for Payer: Humana Medicare |
$75.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$135.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$77.01
|
| Rate for Payer: Kaiser Permanente Medicare |
$75.50
|
| Rate for Payer: MDX Hawaii PPO |
$146.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$75.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$75.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$75.50
|
| Rate for Payer: University Health Alliance Commercial |
$34.26
|
|
|
PH, Fluid FSI
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS 83986
|
| Hospital Charge Code |
8404527
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: Cash Price |
$29.25
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
|
|
PH, Fluid FSI
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS 83986
|
| Hospital Charge Code |
8404527
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.58 |
| Max. Negotiated Rate |
$43.65 |
| Rate for Payer: AlohaCare Medicaid |
$22.50
|
| Rate for Payer: AlohaCare Medicare |
$22.50
|
| Rate for Payer: Cash Price |
$29.25
|
| Rate for Payer: Cash Price |
$29.25
|
| Rate for Payer: Devoted Health Medicare |
$24.75
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$4.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$4.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$5.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3.58
|
| Rate for Payer: Health Management Network Commercial |
$38.25
|
| Rate for Payer: Humana Medicare |
$22.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.50
|
| Rate for Payer: MDX Hawaii PPO |
$43.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$4.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.50
|
| Rate for Payer: University Health Alliance Commercial |
$9.25
|
|
|
Phlebotomy
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
HCPCS 99195
|
| Hospital Charge Code |
8527783
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$14.85 |
| Max. Negotiated Rate |
$545.14 |
| Rate for Payer: AlohaCare Medicaid |
$281.00
|
| Rate for Payer: AlohaCare Medicare |
$281.00
|
| Rate for Payer: Cash Price |
$365.30
|
| Rate for Payer: Cash Price |
$365.30
|
| Rate for Payer: Devoted Health Medicare |
$309.10
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$169.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$281.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$533.90
|
| Rate for Payer: Health Management Network Commercial |
$477.70
|
| Rate for Payer: Humana Medicare |
$281.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$505.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$286.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$281.00
|
| Rate for Payer: MDX Hawaii PPO |
$545.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$281.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$281.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.85
|
| Rate for Payer: UnitedHealthcare Medicare |
$281.00
|
| Rate for Payer: University Health Alliance Commercial |
$314.72
|
|
|
Phlebotomy
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
HCPCS 99195
|
| Hospital Charge Code |
8527783
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$477.70 |
| Max. Negotiated Rate |
$545.14 |
| Rate for Payer: Cash Price |
$365.30
|
| Rate for Payer: Health Management Network Commercial |
$477.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$505.80
|
| Rate for Payer: MDX Hawaii PPO |
$545.14
|
|
|
Phonophoresis Charge
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 97035 GP
|
| Hospital Charge Code |
8111736
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
|
|
Phonophoresis Charge
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 97035 GP
|
| Hospital Charge Code |
8111736
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$100.88 |
| Rate for Payer: AlohaCare Medicaid |
$52.00
|
| Rate for Payer: AlohaCare Medicare |
$52.00
|
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Cash Price |
$67.60
|
| Rate for Payer: Devoted Health Medicare |
$57.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$52.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$98.80
|
| Rate for Payer: Health Management Network Commercial |
$88.40
|
| Rate for Payer: Humana Medicare |
$52.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$93.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$53.04
|
| Rate for Payer: Kaiser Permanente Medicare |
$52.00
|
| Rate for Payer: MDX Hawaii PPO |
$100.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$52.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$52.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$9.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$52.00
|
| Rate for Payer: University Health Alliance Commercial |
$58.24
|
|
|
Phosphorus FSI
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
8118014
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.95 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
|
|
Phosphorus FSI
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
8118014
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$64.99 |
| Rate for Payer: AlohaCare Medicaid |
$33.50
|
| Rate for Payer: AlohaCare Medicare |
$33.50
|
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Cash Price |
$43.55
|
| Rate for Payer: Devoted Health Medicare |
$36.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$6.56
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$5.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$33.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$6.89
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4.74
|
| Rate for Payer: Health Management Network Commercial |
$56.95
|
| Rate for Payer: Humana Medicare |
$33.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$60.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$34.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$33.50
|
| Rate for Payer: MDX Hawaii PPO |
$64.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$33.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$33.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.56
|
| Rate for Payer: UnitedHealthcare Medicare |
$33.50
|
| Rate for Payer: University Health Alliance Commercial |
$12.27
|
|
|
Phosphorus Urine Timed FSI
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS 84105
|
| Hospital Charge Code |
8228908
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$55.29 |
| Rate for Payer: AlohaCare Medicaid |
$28.50
|
| Rate for Payer: AlohaCare Medicare |
$28.50
|
| Rate for Payer: Cash Price |
$37.05
|
| Rate for Payer: Cash Price |
$37.05
|
| Rate for Payer: Devoted Health Medicare |
$31.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$7.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$28.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$7.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5.78
|
| Rate for Payer: Health Management Network Commercial |
$48.45
|
| Rate for Payer: Humana Medicare |
$28.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.07
|
| Rate for Payer: Kaiser Permanente Medicare |
$28.50
|
| Rate for Payer: MDX Hawaii PPO |
$55.29
|
| Rate for Payer: Ohana Health Plan Medicaid |
$28.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$28.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$7.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$28.50
|
| Rate for Payer: University Health Alliance Commercial |
$13.38
|
|
|
Phosphorus Urine Timed FSI
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS 84105
|
| Hospital Charge Code |
8228908
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$55.29 |
| Rate for Payer: Cash Price |
$37.05
|
| Rate for Payer: Health Management Network Commercial |
$48.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.30
|
| Rate for Payer: MDX Hawaii PPO |
$55.29
|
|
|
Phototherapy
|
Facility
|
OP
|
$132.00
|
|
| Hospital Charge Code |
607696
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$66.00 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: AlohaCare Medicaid |
$66.00
|
| Rate for Payer: AlohaCare Medicare |
$66.00
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Devoted Health Medicare |
$72.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$125.40
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Humana Medicare |
$66.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$67.32
|
| Rate for Payer: Kaiser Permanente Medicare |
$66.00
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.00
|
| Rate for Payer: University Health Alliance Commercial |
$73.92
|
|
|
Phototherapy
|
Facility
|
IP
|
$132.00
|
|
| Hospital Charge Code |
607696
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$112.20 |
| Max. Negotiated Rate |
$128.04 |
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Health Management Network Commercial |
$112.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$118.80
|
| Rate for Payer: MDX Hawaii PPO |
$128.04
|
|
