|
EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION [146012]
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J0169
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$29.10 |
| Rate for Payer: AlohaCare Medicaid |
$15.00
|
| Rate for Payer: AlohaCare Medicaid |
$4.50
|
| Rate for Payer: AlohaCare Medicare |
$2.79
|
| Rate for Payer: AlohaCare Medicare |
$9.30
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Devoted Health Medicare |
$10.20
|
| Rate for Payer: Devoted Health Medicare |
$3.06
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$1.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2.79
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.30
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$1.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.55
|
| Rate for Payer: Health Management Network Commercial |
$7.65
|
| Rate for Payer: Health Management Network Commercial |
$25.50
|
| Rate for Payer: Humana Medicare |
$9.30
|
| Rate for Payer: Humana Medicare |
$2.79
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$8.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$4.59
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$2.79
|
| Rate for Payer: MDX Hawaii PPO |
$29.10
|
| Rate for Payer: MDX Hawaii PPO |
$8.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2.79
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.30
|
| Rate for Payer: Ohana Health Plan Medicare |
$2.79
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.30
|
| Rate for Payer: UnitedHealthcare Medicare |
$2.79
|
| Rate for Payer: University Health Alliance Commercial |
$21.87
|
| Rate for Payer: University Health Alliance Commercial |
$6.56
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION [121505]
|
Facility
|
OP
|
$412.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$399.64 |
| Rate for Payer: AlohaCare Medicaid |
$206.00
|
| Rate for Payer: AlohaCare Medicare |
$127.72
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Devoted Health Medicare |
$140.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$127.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$391.40
|
| Rate for Payer: Health Management Network Commercial |
$350.20
|
| Rate for Payer: Humana Medicare |
$127.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$370.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$210.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$127.72
|
| Rate for Payer: MDX Hawaii PPO |
$399.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$127.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$127.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$247.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$127.72
|
| Rate for Payer: University Health Alliance Commercial |
$300.31
|
|
|
EPINEPHRINE 1 MG/ML INJECTION SOLUTION [121505]
|
Facility
|
IP
|
$412.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$350.20 |
| Max. Negotiated Rate |
$399.64 |
| Rate for Payer: Cash Price |
$247.20
|
| Rate for Payer: Health Management Network Commercial |
$350.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$370.80
|
| Rate for Payer: MDX Hawaii PPO |
$399.64
|
|
|
EPINEPHRINE (EPIPEN) 0.3 MG (0.3 ML) (TAKE HOME) [4080358]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
EPINEPHRINE (EPIPEN) 0.3 MG (0.3 ML) (TAKE HOME) [4080358]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
EPINEPHRINE (EPIPEN JR) 0.15 MG (0.3 ML) (TAKE HOME) [4080359]
|
Facility
|
IP
|
$15.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$12.75 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
|
|
EPINEPHRINE (EPIPEN JR) 0.15 MG (0.3 ML) (TAKE HOME) [4080359]
|
Facility
|
OP
|
$15.00
|
|
|
Service Code
|
HCPCS J0165
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$14.55 |
| Rate for Payer: AlohaCare Medicaid |
$7.50
|
| Rate for Payer: AlohaCare Medicare |
$4.65
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Devoted Health Medicare |
$5.10
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.58
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$14.25
|
| Rate for Payer: Health Management Network Commercial |
$12.75
|
| Rate for Payer: Humana Medicare |
$4.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$7.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$4.65
|
| Rate for Payer: MDX Hawaii PPO |
$14.55
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$4.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$4.65
|
| Rate for Payer: University Health Alliance Commercial |
$10.93
|
|
|
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [146332]
|
Facility
|
OP
|
$44.00
|
|
|
Service Code
|
HCPCS J0166
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: AlohaCare Medicaid |
$22.00
|
| Rate for Payer: AlohaCare Medicare |
$13.64
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Devoted Health Medicare |
$14.96
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$13.64
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$41.80
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Humana Medicare |
$13.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$13.64
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.64
|
| Rate for Payer: Ohana Health Plan Medicare |
$13.64
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$13.64
|
| Rate for Payer: University Health Alliance Commercial |
$32.07
|
|
|
EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION [146332]
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
HCPCS J0166
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.40 |
| Max. Negotiated Rate |
$42.68 |
| Rate for Payer: Cash Price |
$26.40
|
| Rate for Payer: Health Management Network Commercial |
$37.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$39.60
|
| Rate for Payer: MDX Hawaii PPO |
$42.68
|
|
|
EPINEPHRINE INFUSION 8 MCG/ML IN 250 ML NS-CNR (SIMPLE) [4080073]
|
Facility
|
IP
|
$71.00
|
|
|
Service Code
|
NDC 00004080024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.35 |
| Max. Negotiated Rate |
$68.87 |
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Health Management Network Commercial |
$60.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$63.90
|
| Rate for Payer: MDX Hawaii PPO |
$68.87
|
|
|
EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR [124985]
|
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: Health Management Network Commercial |
$239.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$253.80
|
| Rate for Payer: MDX Hawaii PPO |
$273.54
|
|
|
EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR [124985]
|
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 Medicare |
$87.42
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Cash Price |
$169.20
|
| Rate for Payer: Devoted Health Medicare |
$95.88
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.58
|
| 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 Western Management Group Commercial |
$267.90
|
| Rate for Payer: Health Management Network Commercial |
$239.70
|
| Rate for Payer: Humana Medicare |
$87.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$253.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$143.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$87.42
|
| Rate for Payer: MDX Hawaii PPO |
$273.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$87.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$87.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$169.20
|
| Rate for Payer: UnitedHealthcare Medicare |
$87.42
|
| Rate for Payer: University Health Alliance Commercial |
$205.55
|
|
|
EPISTAXIS WITH MCC
|
Facility
|
IP
|
$10,405.18
|
|
|
Service Code
|
MSDRG 150
|
| Min. Negotiated Rate |
$10,405.18 |
| Max. Negotiated Rate |
$10,405.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,405.18
|
|
|
EPISTAXIS WITHOUT MCC
|
Facility
|
IP
|
$10,405.18
|
|
|
Service Code
|
MSDRG 151
|
| Min. Negotiated Rate |
$10,405.18 |
| Max. Negotiated Rate |
$10,405.18 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10,405.18
|
|
|
EPIX LAPAROSCOPIC GRASPER 5MM
|
Facility
|
OP
|
$360.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.60 |
| Max. Negotiated Rate |
$349.20 |
| Rate for Payer: AlohaCare Medicaid |
$180.00
|
| Rate for Payer: AlohaCare Medicare |
$111.60
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Devoted Health Medicare |
$122.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$342.00
|
| Rate for Payer: Health Management Network Commercial |
$306.00
|
| Rate for Payer: Humana Medicare |
$111.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$324.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$183.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.60
|
| Rate for Payer: MDX Hawaii PPO |
$349.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$111.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.60
|
| Rate for Payer: University Health Alliance Commercial |
$262.40
|
|
|
EPIX LAPAROSCOPIC GRASPER 5MM
|
Facility
|
IP
|
$360.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$306.00 |
| Max. Negotiated Rate |
$349.20 |
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Health Management Network Commercial |
$306.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$324.00
|
| Rate for Payer: MDX Hawaii PPO |
$349.20
|
|
|
EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]
|
Facility
|
IP
|
$963.00
|
|
|
Service Code
|
HCPCS Q4081
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$818.55 |
| Max. Negotiated Rate |
$934.11 |
| Rate for Payer: Cash Price |
$577.80
|
| Rate for Payer: Cash Price |
$358.20
|
| Rate for Payer: Health Management Network Commercial |
$818.55
|
| Rate for Payer: Health Management Network Commercial |
$507.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$537.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$866.70
|
| Rate for Payer: MDX Hawaii PPO |
$579.09
|
| Rate for Payer: MDX Hawaii PPO |
$934.11
|
|
|
EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION [14643]
|
Facility
|
OP
|
$597.00
|
|
|
Service Code
|
HCPCS Q4081
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$579.09 |
| Rate for Payer: AlohaCare Medicaid |
$298.50
|
| Rate for Payer: AlohaCare Medicaid |
$481.50
|
| Rate for Payer: AlohaCare Medicare |
$298.53
|
| Rate for Payer: AlohaCare Medicare |
$185.07
|
| Rate for Payer: Cash Price |
$577.80
|
| Rate for Payer: Cash Price |
$358.20
|
| Rate for Payer: Cash Price |
$577.80
|
| Rate for Payer: Cash Price |
$358.20
|
| Rate for Payer: Devoted Health Medicare |
$202.98
|
| Rate for Payer: Devoted Health Medicare |
$327.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.77
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$185.07
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$298.53
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.77
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$567.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$914.85
|
| Rate for Payer: Health Management Network Commercial |
$507.45
|
| Rate for Payer: Health Management Network Commercial |
$818.55
|
| Rate for Payer: Humana Medicare |
$298.53
|
| Rate for Payer: Humana Medicare |
$185.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$537.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$866.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$304.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$491.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$298.53
|
| Rate for Payer: Kaiser Permanente Medicare |
$185.07
|
| Rate for Payer: MDX Hawaii PPO |
$934.11
|
| Rate for Payer: MDX Hawaii PPO |
$579.09
|
| Rate for Payer: Ohana Health Plan Medicaid |
$298.53
|
| Rate for Payer: Ohana Health Plan Medicaid |
$185.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$185.07
|
| Rate for Payer: Ohana Health Plan Medicare |
$298.53
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.58
|
| Rate for Payer: UnitedHealthcare Medicare |
$298.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$185.07
|
| Rate for Payer: University Health Alliance Commercial |
$701.93
|
| Rate for Payer: University Health Alliance Commercial |
$435.15
|
|
|
EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [160716]
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: AlohaCare Medicaid |
$99.50
|
| Rate for Payer: AlohaCare Medicare |
$61.69
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Devoted Health Medicare |
$67.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$61.69
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$189.05
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Humana Medicare |
$61.69
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$101.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$61.69
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$61.69
|
| Rate for Payer: Ohana Health Plan Medicare |
$61.69
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$61.69
|
| Rate for Payer: University Health Alliance Commercial |
$145.05
|
|
|
EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION [160716]
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$169.15 |
| Max. Negotiated Rate |
$193.03 |
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Health Management Network Commercial |
$169.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$179.10
|
| Rate for Payer: MDX Hawaii PPO |
$193.03
|
|
|
EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [176329]
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$338.30 |
| Max. Negotiated Rate |
$386.06 |
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Health Management Network Commercial |
$338.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$358.20
|
| Rate for Payer: MDX Hawaii PPO |
$386.06
|
|
|
EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION [176329]
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$386.06 |
| Rate for Payer: AlohaCare Medicaid |
$199.00
|
| Rate for Payer: AlohaCare Medicare |
$123.38
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Cash Price |
$238.80
|
| Rate for Payer: Devoted Health Medicare |
$135.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$123.38
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$378.10
|
| Rate for Payer: Health Management Network Commercial |
$338.30
|
| Rate for Payer: Humana Medicare |
$123.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$358.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$202.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$123.38
|
| Rate for Payer: MDX Hawaii PPO |
$386.06
|
| Rate for Payer: Ohana Health Plan Medicaid |
$123.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$123.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$123.38
|
| Rate for Payer: University Health Alliance Commercial |
$290.10
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [160717]
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$675.75 |
| Max. Negotiated Rate |
$771.15 |
| Rate for Payer: Cash Price |
$477.00
|
| Rate for Payer: Health Management Network Commercial |
$675.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$715.50
|
| Rate for Payer: MDX Hawaii PPO |
$771.15
|
|
|
EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION [160717]
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$771.15 |
| Rate for Payer: AlohaCare Medicaid |
$397.50
|
| Rate for Payer: AlohaCare Medicare |
$246.45
|
| Rate for Payer: Cash Price |
$477.00
|
| Rate for Payer: Cash Price |
$477.00
|
| Rate for Payer: Devoted Health Medicare |
$270.30
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.45
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$755.25
|
| Rate for Payer: Health Management Network Commercial |
$675.75
|
| Rate for Payer: Humana Medicare |
$246.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$715.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$405.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.45
|
| Rate for Payer: MDX Hawaii PPO |
$771.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$246.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$246.45
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.45
|
| Rate for Payer: University Health Alliance Commercial |
$579.48
|
|
|
EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [160715]
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
HCPCS Q5105
|
|
Hospital Revenue Code
|
634
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: AlohaCare Medicaid |
$53.00
|
| Rate for Payer: AlohaCare Medicare |
$32.86
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Cash Price |
$63.60
|
| Rate for Payer: Devoted Health Medicare |
$36.04
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$0.76
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$32.86
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$0.76
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$100.70
|
| Rate for Payer: Health Management Network Commercial |
$90.10
|
| Rate for Payer: Humana Medicare |
$32.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$95.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$54.06
|
| Rate for Payer: Kaiser Permanente Medicare |
$32.86
|
| Rate for Payer: MDX Hawaii PPO |
$102.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$32.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$32.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.57
|
| Rate for Payer: UnitedHealthcare Medicare |
$32.86
|
| Rate for Payer: University Health Alliance Commercial |
$77.26
|
|
