|
ENROUTE RX BALLOON SR-5025-BC
|
Facility
|
IP
|
$1,397.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,187.45 |
| Max. Negotiated Rate |
$1,355.09 |
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Health Management Network Commercial |
$1,187.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,257.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,355.09
|
|
|
ENROUTE RX BALLOON SR-5525-BC
|
Facility
|
OP
|
$1,397.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$433.07 |
| Max. Negotiated Rate |
$1,355.09 |
| Rate for Payer: AlohaCare Medicaid |
$698.50
|
| Rate for Payer: AlohaCare Medicare |
$433.07
|
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Devoted Health Medicare |
$474.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$433.07
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,327.15
|
| Rate for Payer: Health Management Network Commercial |
$1,187.45
|
| Rate for Payer: Humana Medicare |
$433.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,257.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$712.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$433.07
|
| Rate for Payer: MDX Hawaii PPO |
$1,355.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$433.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$433.07
|
| Rate for Payer: UnitedHealthcare Medicare |
$433.07
|
| Rate for Payer: University Health Alliance Commercial |
$1,018.27
|
|
|
ENROUTE RX BALLOON SR-5525-BC
|
Facility
|
IP
|
$1,397.00
|
|
|
Service Code
|
HCPCS C1725
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,187.45 |
| Max. Negotiated Rate |
$1,355.09 |
| Rate for Payer: Cash Price |
$838.20
|
| Rate for Payer: Health Management Network Commercial |
$1,187.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,257.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,355.09
|
|
|
ENROUTE STENT SYS SR-0830-CS
|
Facility
|
OP
|
$5,400.00
|
|
|
Service Code
|
HCPCS C1876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.00 |
| Max. Negotiated Rate |
$5,238.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,700.00
|
| Rate for Payer: AlohaCare Medicare |
$1,674.00
|
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Devoted Health Medicare |
$1,836.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,674.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,780.00
|
| Rate for Payer: Health Management Network Commercial |
$4,590.00
|
| Rate for Payer: Humana Medicare |
$1,674.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,860.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,754.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,674.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,238.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,674.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,674.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,674.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,024.00
|
|
|
ENROUTE STENT SYS SR-0830-CS
|
Facility
|
IP
|
$5,400.00
|
|
|
Service Code
|
HCPCS C1876
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,024.00 |
| Max. Negotiated Rate |
$5,238.00 |
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,780.00
|
| Rate for Payer: Health Management Network Commercial |
$4,590.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,860.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,238.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,024.00
|
|
|
ENROUTE TRANSCAROTD SR-0930-CS
|
Facility
|
IP
|
$5,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,024.00 |
| Max. Negotiated Rate |
$5,238.00 |
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,780.00
|
| Rate for Payer: Health Management Network Commercial |
$4,590.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,860.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,238.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,024.00
|
|
|
ENROUTE TRANSCAROTD SR-0930-CS
|
Facility
|
OP
|
$5,400.00
|
|
|
Service Code
|
HCPCS C1776
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.00 |
| Max. Negotiated Rate |
$5,238.00 |
| Rate for Payer: AlohaCare Medicaid |
$2,700.00
|
| Rate for Payer: AlohaCare Medicare |
$1,674.00
|
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Devoted Health Medicare |
$1,836.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,674.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,780.00
|
| Rate for Payer: Health Management Network Commercial |
$4,590.00
|
| Rate for Payer: Humana Medicare |
$1,674.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$4,860.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$2,754.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,674.00
|
| Rate for Payer: MDX Hawaii PPO |
$5,238.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,674.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,674.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,674.00
|
| Rate for Payer: University Health Alliance Commercial |
$3,024.00
|
|
|
ENROUTE TRANSCAROT SR-250-NPS
|
Facility
|
IP
|
$16,590.00
|
|
|
Service Code
|
HCPCS C1884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,290.40 |
| Max. Negotiated Rate |
$16,092.30 |
| Rate for Payer: Cash Price |
$9,954.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,613.00
|
| Rate for Payer: Health Management Network Commercial |
$14,101.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,931.00
|
| Rate for Payer: MDX Hawaii PPO |
$16,092.30
|
| Rate for Payer: University Health Alliance Commercial |
$9,290.40
|
|
|
ENROUTE TRANSCAROT SR-250-NPS
|
Facility
|
OP
|
$16,590.00
|
|
|
Service Code
|
HCPCS C1884
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,142.90 |
| Max. Negotiated Rate |
$16,092.30 |
| Rate for Payer: AlohaCare Medicaid |
$8,295.00
|
| Rate for Payer: AlohaCare Medicare |
$5,142.90
|
| Rate for Payer: Cash Price |
$9,954.00
|
| Rate for Payer: Devoted Health Medicare |
$5,640.60
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,142.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$11,613.00
|
| Rate for Payer: Health Management Network Commercial |
$14,101.50
|
| Rate for Payer: Humana Medicare |
$5,142.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$14,931.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$8,460.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,142.90
|
| Rate for Payer: MDX Hawaii PPO |
$16,092.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,142.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,142.90
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,142.90
|
| Rate for Payer: University Health Alliance Commercial |
$9,290.40
|
|
|
ENSEAL X1 CURVED NSLX137C
|
Facility
|
OP
|
$2,613.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$810.03 |
| Max. Negotiated Rate |
$2,534.61 |
| Rate for Payer: AlohaCare Medicaid |
$1,306.50
|
| Rate for Payer: AlohaCare Medicare |
$810.03
|
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Devoted Health Medicare |
$888.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$810.03
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,482.35
|
| Rate for Payer: Health Management Network Commercial |
$2,221.05
|
| Rate for Payer: Humana Medicare |
$810.03
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,351.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$1,332.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$810.03
|
| Rate for Payer: MDX Hawaii PPO |
$2,534.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$810.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$810.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$810.03
|
| Rate for Payer: University Health Alliance Commercial |
$1,904.62
|
|
|
ENSEAL X1 CURVED NSLX137C
|
Facility
|
IP
|
$2,613.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,221.05 |
| Max. Negotiated Rate |
$2,534.61 |
| Rate for Payer: Cash Price |
$1,567.80
|
| Rate for Payer: Health Management Network Commercial |
$2,221.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,351.70
|
| Rate for Payer: MDX Hawaii PPO |
$2,534.61
|
|
|
EPHEDRINE (PF) 50 MG/5 ML (10 MG/ML) IN 0.9% SOD. CHLORIDE IV SYRINGE [132373]
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 71266904505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.65 |
| Max. Negotiated Rate |
$8.73 |
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
NDC 00781326995
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
NDC 00781326971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$101.15 |
| Max. Negotiated Rate |
$115.43 |
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Health Management Network Commercial |
$101.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$107.10
|
| Rate for Payer: MDX Hawaii PPO |
$115.43
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
NDC 70121163707
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$110.58 |
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Health Management Network Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$102.60
|
| Rate for Payer: MDX Hawaii PPO |
$110.58
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 43598072511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Health Management Network Commercial |
$4.25
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$4.50
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
| Rate for Payer: MDX Hawaii PPO |
$4.85
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 51754420004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$29.00
|
|
|
Service Code
|
NDC 00641623825
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.65 |
| Max. Negotiated Rate |
$28.13 |
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Health Management Network Commercial |
$24.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.10
|
| Rate for Payer: MDX Hawaii PPO |
$28.13
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 43598072525
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION [132566]
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 51754420001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.95 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Cash Price |
$28.20
|
| Rate for Payer: Health Management Network Commercial |
$39.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$42.30
|
| Rate for Payer: MDX Hawaii PPO |
$45.59
|
|
|
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE [162620]
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS J0168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.55 |
| Max. Negotiated Rate |
$41.71 |
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
|
|
EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE [162620]
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
HCPCS J0168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: AlohaCare Medicaid |
$29.00
|
| Rate for Payer: AlohaCare Medicaid |
$21.50
|
| Rate for Payer: AlohaCare Medicare |
$13.33
|
| Rate for Payer: AlohaCare Medicare |
$17.98
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$25.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Devoted Health Medicare |
$14.62
|
| Rate for Payer: Devoted Health Medicare |
$19.72
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.33
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17.98
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$55.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$40.85
|
| Rate for Payer: Health Management Network Commercial |
$36.55
|
| Rate for Payer: Health Management Network Commercial |
$49.30
|
| Rate for Payer: Humana Medicare |
$17.98
|
| Rate for Payer: Humana Medicare |
$13.33
|
| Rate for Payer: Kaiser Permanente Commercial |
$38.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$52.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$29.58
|
| Rate for Payer: Kaiser Permanente Medicaid |
$21.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.98
|
| Rate for Payer: MDX Hawaii PPO |
$56.26
|
| Rate for Payer: MDX Hawaii PPO |
$41.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$17.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.33
|
| Rate for Payer: UnitedHealthcare Medicaid |
$34.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$25.80
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$17.98
|
| Rate for Payer: University Health Alliance Commercial |
$42.28
|
| Rate for Payer: University Health Alliance Commercial |
$31.34
|
|
|
EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR [124987]
|
Facility
|
OP
|
$282.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$273.54 |
| Rate for Payer: AlohaCare Medicaid |
$141.00
|
| Rate for Payer: AlohaCare Medicaid |
$185.50
|
| Rate for Payer: AlohaCare Medicare |
$115.01
|
| Rate for Payer: AlohaCare Medicare |
$87.42
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Devoted Health Medicare |
$95.88
|
| Rate for Payer: Devoted Health Medicare |
$126.14
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$115.01
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$87.42
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.58
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$267.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$352.45
|
| Rate for Payer: Health Management Network Commercial |
$315.35
|
| Rate for Payer: Health Management Network Commercial |
$239.70
|
| Rate for Payer: Humana Medicare |
$87.42
|
| Rate for Payer: Humana Medicare |
$115.01
|
| Rate for Payer: Kaiser Permanente Commercial |
$253.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$189.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$143.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$115.01
|
| Rate for Payer: MDX Hawaii PPO |
$273.54
|
| Rate for Payer: MDX Hawaii PPO |
$359.87
|
| Rate for Payer: Ohana Health Plan Medicaid |
$115.01
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$115.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$222.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$169.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$115.01
|
| Rate for Payer: University Health Alliance Commercial |
$205.55
|
| Rate for Payer: University Health Alliance Commercial |
$270.42
|
|
|
EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR [124987]
|
Facility
|
IP
|
$282.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$239.70 |
| Max. Negotiated Rate |
$273.54 |
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$222.60
|
| Rate for Payer: Health Management Network Commercial |
$239.70
|
| Rate for Payer: Health Management Network Commercial |
$315.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$253.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$333.90
|
| Rate for Payer: MDX Hawaii PPO |
$359.87
|
| Rate for Payer: MDX Hawaii PPO |
$273.54
|
|
|
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [146012]
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J0169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.50 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
|
