|
ePHEDrine 50 mg/10 mL (PF) vial [HHSC]
|
Facility
|
OP
|
$163.61
|
|
|
Service Code
|
NDC 42023024301
|
| Hospital Charge Code |
2501096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.81 |
| Max. Negotiated Rate |
$158.70 |
| Rate for Payer: AlohaCare Medicaid |
$81.81
|
| Rate for Payer: AlohaCare Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$106.35
|
| Rate for Payer: Devoted Health Medicare |
$89.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.43
|
| Rate for Payer: Health Management Network Commercial |
$139.07
|
| Rate for Payer: Humana Medicare |
$81.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.81
|
| Rate for Payer: MDX Hawaii PPO |
$158.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.81
|
| Rate for Payer: University Health Alliance Commercial |
$119.26
|
|
|
ePHEDrine 50 mg/10 mL (PF) vial [HHSC]
|
Facility
|
IP
|
$163.61
|
|
|
Service Code
|
NDC 42023024301
|
| Hospital Charge Code |
2501096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.07 |
| Max. Negotiated Rate |
$158.70 |
| Rate for Payer: Cash Price |
$106.35
|
| Rate for Payer: Health Management Network Commercial |
$139.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.25
|
| Rate for Payer: MDX Hawaii PPO |
$158.70
|
|
|
ePHEDrine 50 mg/10 mL (PF) vial [HHSC]
|
Facility
|
IP
|
$163.61
|
|
|
Service Code
|
NDC 14789025010
|
| Hospital Charge Code |
2501096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.07 |
| Max. Negotiated Rate |
$158.70 |
| Rate for Payer: Cash Price |
$106.35
|
| Rate for Payer: Health Management Network Commercial |
$139.07
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.25
|
| Rate for Payer: MDX Hawaii PPO |
$158.70
|
|
|
ePHEDrine 50 mg/10 mL (PF) vial [HHSC]
|
Facility
|
OP
|
$163.61
|
|
|
Service Code
|
NDC 14789025010
|
| Hospital Charge Code |
2501096
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.81 |
| Max. Negotiated Rate |
$158.70 |
| Rate for Payer: AlohaCare Medicaid |
$81.81
|
| Rate for Payer: AlohaCare Medicare |
$81.81
|
| Rate for Payer: Cash Price |
$106.35
|
| Rate for Payer: Devoted Health Medicare |
$89.99
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.43
|
| Rate for Payer: Health Management Network Commercial |
$139.07
|
| Rate for Payer: Humana Medicare |
$81.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.25
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.44
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.81
|
| Rate for Payer: MDX Hawaii PPO |
$158.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.17
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.81
|
| Rate for Payer: University Health Alliance Commercial |
$119.26
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
OP
|
$95.40
|
|
|
Service Code
|
NDC 43598072525
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.70 |
| Max. Negotiated Rate |
$92.54 |
| Rate for Payer: AlohaCare Medicaid |
$47.70
|
| Rate for Payer: AlohaCare Medicare |
$47.70
|
| Rate for Payer: Cash Price |
$62.01
|
| Rate for Payer: Devoted Health Medicare |
$52.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.63
|
| Rate for Payer: Health Management Network Commercial |
$81.09
|
| Rate for Payer: Humana Medicare |
$47.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$48.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$47.70
|
| Rate for Payer: MDX Hawaii PPO |
$92.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$47.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$57.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.70
|
| Rate for Payer: University Health Alliance Commercial |
$69.54
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
OP
|
$55.20
|
|
|
Service Code
|
NDC 65219025701
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.60 |
| Max. Negotiated Rate |
$53.54 |
| Rate for Payer: AlohaCare Medicaid |
$27.60
|
| Rate for Payer: AlohaCare Medicare |
$27.60
|
| Rate for Payer: Cash Price |
$35.88
|
| Rate for Payer: Devoted Health Medicare |
$30.36
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$27.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$52.44
|
| Rate for Payer: Health Management Network Commercial |
$46.92
|
| Rate for Payer: Humana Medicare |
$27.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$28.15
|
| Rate for Payer: Kaiser Permanente Medicare |
$27.60
|
| Rate for Payer: MDX Hawaii PPO |
$53.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$27.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$27.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$33.12
|
| Rate for Payer: UnitedHealthcare Medicare |
$27.60
|
| Rate for Payer: University Health Alliance Commercial |
$40.24
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
IP
|
$55.20
|
|
|
Service Code
|
NDC 65219025701
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.92 |
| Max. Negotiated Rate |
$53.54 |
| Rate for Payer: Cash Price |
$35.88
|
| Rate for Payer: Health Management Network Commercial |
$46.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$49.68
|
| Rate for Payer: MDX Hawaii PPO |
$53.54
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
IP
|
$95.40
|
|
|
Service Code
|
NDC 43598072525
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.09 |
| Max. Negotiated Rate |
$92.54 |
| Rate for Payer: Cash Price |
$62.01
|
| Rate for Payer: Health Management Network Commercial |
$81.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$85.86
|
| Rate for Payer: MDX Hawaii PPO |
$92.54
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
OP
|
$297.91
|
|
|
Service Code
|
NDC 17478041510
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$148.96 |
| Max. Negotiated Rate |
$288.97 |
| Rate for Payer: AlohaCare Medicaid |
$148.96
|
| Rate for Payer: AlohaCare Medicare |
$148.96
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Devoted Health Medicare |
$163.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$148.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$283.01
|
| Rate for Payer: Health Management Network Commercial |
$253.22
|
| Rate for Payer: Humana Medicare |
$148.96
|
| Rate for Payer: Kaiser Permanente Commercial |
$268.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$151.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$148.96
|
| Rate for Payer: MDX Hawaii PPO |
$288.97
|
| Rate for Payer: Ohana Health Plan Medicaid |
$148.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$148.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$178.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$148.96
|
| Rate for Payer: University Health Alliance Commercial |
$217.15
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
IP
|
$163.81
|
|
|
Service Code
|
NDC 42023021625
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$139.24 |
| Max. Negotiated Rate |
$158.90 |
| Rate for Payer: Cash Price |
$106.48
|
| Rate for Payer: Health Management Network Commercial |
$139.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.43
|
| Rate for Payer: MDX Hawaii PPO |
$158.90
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
OP
|
$163.81
|
|
|
Service Code
|
NDC 42023021625
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$81.91 |
| Max. Negotiated Rate |
$158.90 |
| Rate for Payer: AlohaCare Medicaid |
$81.91
|
| Rate for Payer: AlohaCare Medicare |
$81.91
|
| Rate for Payer: Cash Price |
$106.48
|
| Rate for Payer: Devoted Health Medicare |
$90.10
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$81.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$155.62
|
| Rate for Payer: Health Management Network Commercial |
$139.24
|
| Rate for Payer: Humana Medicare |
$81.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$147.43
|
| Rate for Payer: Kaiser Permanente Medicaid |
$83.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$81.91
|
| Rate for Payer: MDX Hawaii PPO |
$158.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$81.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$81.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$98.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$81.91
|
| Rate for Payer: University Health Alliance Commercial |
$119.40
|
|
|
ePHEDrine 50 mg/mL ampule [HHSC]
|
Facility
|
IP
|
$297.91
|
|
|
Service Code
|
NDC 17478041510
|
| Hospital Charge Code |
2500293
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$253.22 |
| Max. Negotiated Rate |
$288.97 |
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Health Management Network Commercial |
$253.22
|
| Rate for Payer: Kaiser Permanente Commercial |
$268.12
|
| Rate for Payer: MDX Hawaii PPO |
$288.97
|
|
|
epi-lidocaine 4%-BSS 4 mL cmpd [HHSC]
|
Facility
|
IP
|
$108.68
|
|
|
Service Code
|
NDC 99999999966
|
| Hospital Charge Code |
2501035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$92.38 |
| Max. Negotiated Rate |
$105.42 |
| Rate for Payer: Cash Price |
$70.64
|
| Rate for Payer: Health Management Network Commercial |
$92.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.81
|
| Rate for Payer: MDX Hawaii PPO |
$105.42
|
|
|
epi-lidocaine 4%-BSS 4 mL cmpd [HHSC]
|
Facility
|
OP
|
$108.68
|
|
|
Service Code
|
NDC 99999999966
|
| Hospital Charge Code |
2501035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$105.42 |
| Rate for Payer: AlohaCare Medicaid |
$54.34
|
| Rate for Payer: AlohaCare Medicare |
$54.34
|
| Rate for Payer: Cash Price |
$70.64
|
| Rate for Payer: Devoted Health Medicare |
$59.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$54.34
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$103.25
|
| Rate for Payer: Health Management Network Commercial |
$92.38
|
| Rate for Payer: Humana Medicare |
$54.34
|
| Rate for Payer: Kaiser Permanente Commercial |
$97.81
|
| Rate for Payer: Kaiser Permanente Medicaid |
$55.43
|
| Rate for Payer: Kaiser Permanente Medicare |
$54.34
|
| Rate for Payer: MDX Hawaii PPO |
$105.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.34
|
| Rate for Payer: Ohana Health Plan Medicare |
$54.34
|
| Rate for Payer: UnitedHealthcare Medicaid |
$65.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$54.34
|
| Rate for Payer: University Health Alliance Commercial |
$79.22
|
|
|
Epinephrine 0.2mg/ 500ml BSS [HHSC]
|
Facility
|
OP
|
$19.46
|
|
|
Service Code
|
NDC 99999999970
|
| Hospital Charge Code |
2500976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.73 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: AlohaCare Medicaid |
$9.73
|
| Rate for Payer: AlohaCare Medicare |
$9.73
|
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: Devoted Health Medicare |
$10.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$9.73
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$18.49
|
| Rate for Payer: Health Management Network Commercial |
$16.54
|
| Rate for Payer: Humana Medicare |
$9.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$9.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$9.73
|
| Rate for Payer: MDX Hawaii PPO |
$18.88
|
| Rate for Payer: Ohana Health Plan Medicaid |
$9.73
|
| Rate for Payer: Ohana Health Plan Medicare |
$9.73
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$9.73
|
| Rate for Payer: University Health Alliance Commercial |
$14.18
|
|
|
Epinephrine 0.2mg/ 500ml BSS [HHSC]
|
Facility
|
IP
|
$19.46
|
|
|
Service Code
|
NDC 99999999970
|
| Hospital Charge Code |
2500976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.54 |
| Max. Negotiated Rate |
$18.88 |
| Rate for Payer: Cash Price |
$12.65
|
| Rate for Payer: Health Management Network Commercial |
$16.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.51
|
| Rate for Payer: MDX Hawaii PPO |
$18.88
|
|
|
Epinephrine 0.3mg/ 500ml BSS [HHSC]
|
Facility
|
OP
|
$29.19
|
|
|
Service Code
|
NDC 99999999971
|
| Hospital Charge Code |
2500977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.60 |
| Max. Negotiated Rate |
$28.31 |
| Rate for Payer: AlohaCare Medicaid |
$14.60
|
| Rate for Payer: AlohaCare Medicare |
$14.60
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Devoted Health Medicare |
$16.05
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$27.73
|
| Rate for Payer: Health Management Network Commercial |
$24.81
|
| Rate for Payer: Humana Medicare |
$14.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$14.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$14.60
|
| Rate for Payer: MDX Hawaii PPO |
$28.31
|
| Rate for Payer: Ohana Health Plan Medicaid |
$14.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.60
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.60
|
| Rate for Payer: University Health Alliance Commercial |
$21.28
|
|
|
Epinephrine 0.3mg/ 500ml BSS [HHSC]
|
Facility
|
IP
|
$29.19
|
|
|
Service Code
|
NDC 99999999971
|
| Hospital Charge Code |
2500977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.81 |
| Max. Negotiated Rate |
$28.31 |
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Health Management Network Commercial |
$24.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$26.27
|
| Rate for Payer: MDX Hawaii PPO |
$28.31
|
|
|
EPINEPHrine 10 mg/10 mL MDV [HHSC]
|
Facility
|
IP
|
$467.72
|
|
|
Service Code
|
NDC 54288012001
|
| Hospital Charge Code |
2501140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.56 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
|
|
EPINEPHrine 10 mg/10 mL MDV [HHSC]
|
Facility
|
IP
|
$413.63
|
|
|
Service Code
|
NDC 54288060001
|
| Hospital Charge Code |
2501140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$351.59 |
| Max. Negotiated Rate |
$401.22 |
| Rate for Payer: Cash Price |
$268.86
|
| Rate for Payer: Health Management Network Commercial |
$351.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$372.27
|
| Rate for Payer: MDX Hawaii PPO |
$401.22
|
|
|
EPINEPHrine 10 mg/10 mL MDV [HHSC]
|
Facility
|
OP
|
$413.63
|
|
|
Service Code
|
NDC 54288060001
|
| Hospital Charge Code |
2501140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$206.81 |
| Max. Negotiated Rate |
$401.22 |
| Rate for Payer: AlohaCare Medicaid |
$206.81
|
| Rate for Payer: AlohaCare Medicare |
$206.81
|
| Rate for Payer: Cash Price |
$268.86
|
| Rate for Payer: Devoted Health Medicare |
$227.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$206.81
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$392.95
|
| Rate for Payer: Health Management Network Commercial |
$351.59
|
| Rate for Payer: Humana Medicare |
$206.81
|
| Rate for Payer: Kaiser Permanente Commercial |
$372.27
|
| Rate for Payer: Kaiser Permanente Medicaid |
$210.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$206.81
|
| Rate for Payer: MDX Hawaii PPO |
$401.22
|
| Rate for Payer: Ohana Health Plan Medicaid |
$206.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$206.81
|
| Rate for Payer: UnitedHealthcare Medicaid |
$248.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$206.81
|
| Rate for Payer: University Health Alliance Commercial |
$301.49
|
|
|
EPINEPHrine 10 mg/10 mL MDV [HHSC]
|
Facility
|
OP
|
$467.72
|
|
|
Service Code
|
NDC 54288012001
|
| Hospital Charge Code |
2501140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$233.86 |
| Max. Negotiated Rate |
$453.69 |
| Rate for Payer: AlohaCare Medicaid |
$233.86
|
| Rate for Payer: AlohaCare Medicare |
$233.86
|
| Rate for Payer: Cash Price |
$304.02
|
| Rate for Payer: Devoted Health Medicare |
$257.25
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$233.86
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$444.33
|
| Rate for Payer: Health Management Network Commercial |
$397.56
|
| Rate for Payer: Humana Medicare |
$233.86
|
| Rate for Payer: Kaiser Permanente Commercial |
$420.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.54
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.86
|
| Rate for Payer: MDX Hawaii PPO |
$453.69
|
| Rate for Payer: Ohana Health Plan Medicaid |
$233.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$233.86
|
| Rate for Payer: UnitedHealthcare Medicaid |
$280.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$233.86
|
| Rate for Payer: University Health Alliance Commercial |
$340.92
|
|
|
EPINEPHrine 1mg/10ml syringe [HHSC]
|
Facility
|
IP
|
$40.29
|
|
|
Service Code
|
HCPCS J0168
|
| Hospital Charge Code |
2500294
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.25 |
| Max. Negotiated Rate |
$39.08 |
| Rate for Payer: Cash Price |
$26.19
|
| Rate for Payer: Cash Price |
$19.77
|
| Rate for Payer: Cash Price |
$52.55
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Health Management Network Commercial |
$25.86
|
| Rate for Payer: Health Management Network Commercial |
$34.25
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Health Management Network Commercial |
$68.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.77
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.26
|
| Rate for Payer: MDX Hawaii PPO |
$29.51
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$78.42
|
| Rate for Payer: MDX Hawaii PPO |
$39.08
|
|
|
EPINEPHrine 1mg/10ml syringe [HHSC]
|
Facility
|
OP
|
$44.74
|
|
|
Service Code
|
HCPCS J0168
|
| Hospital Charge Code |
2500294
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.18 |
| Max. Negotiated Rate |
$43.40 |
| Rate for Payer: AlohaCare Medicaid |
$22.37
|
| Rate for Payer: AlohaCare Medicaid |
$40.42
|
| Rate for Payer: AlohaCare Medicaid |
$20.14
|
| Rate for Payer: AlohaCare Medicaid |
$15.21
|
| Rate for Payer: AlohaCare Medicare |
$15.21
|
| Rate for Payer: AlohaCare Medicare |
$20.14
|
| Rate for Payer: AlohaCare Medicare |
$22.37
|
| Rate for Payer: AlohaCare Medicare |
$40.42
|
| Rate for Payer: Cash Price |
$19.77
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$26.19
|
| Rate for Payer: Cash Price |
$26.19
|
| Rate for Payer: Cash Price |
$29.08
|
| Rate for Payer: Cash Price |
$52.55
|
| Rate for Payer: Cash Price |
$19.77
|
| Rate for Payer: Cash Price |
$52.55
|
| Rate for Payer: Devoted Health Medicare |
$22.16
|
| Rate for Payer: Devoted Health Medicare |
$24.61
|
| Rate for Payer: Devoted Health Medicare |
$16.73
|
| Rate for Payer: Devoted Health Medicare |
$44.47
|
| 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 ABD |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.18
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$20.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$40.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.21
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$22.37
|
| 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 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 |
$42.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$28.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$38.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.81
|
| Rate for Payer: Health Management Network Commercial |
$68.72
|
| Rate for Payer: Health Management Network Commercial |
$34.25
|
| Rate for Payer: Health Management Network Commercial |
$25.86
|
| Rate for Payer: Health Management Network Commercial |
$38.03
|
| Rate for Payer: Humana Medicare |
$20.14
|
| Rate for Payer: Humana Medicare |
$15.21
|
| Rate for Payer: Humana Medicare |
$22.37
|
| Rate for Payer: Humana Medicare |
$40.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$40.27
|
| Rate for Payer: Kaiser Permanente Commercial |
$36.26
|
| Rate for Payer: Kaiser Permanente Commercial |
$27.38
|
| Rate for Payer: Kaiser Permanente Commercial |
$72.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$22.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.23
|
| Rate for Payer: Kaiser Permanente Medicaid |
$20.55
|
| Rate for Payer: Kaiser Permanente Medicare |
$40.42
|
| Rate for Payer: Kaiser Permanente Medicare |
$20.14
|
| Rate for Payer: Kaiser Permanente Medicare |
$22.37
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.21
|
| Rate for Payer: MDX Hawaii PPO |
$78.42
|
| Rate for Payer: MDX Hawaii PPO |
$43.40
|
| Rate for Payer: MDX Hawaii PPO |
$39.08
|
| Rate for Payer: MDX Hawaii PPO |
$29.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$20.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$15.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicaid |
$40.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$20.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$22.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$40.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.17
|
| Rate for Payer: UnitedHealthcare Medicaid |
$26.84
|
| Rate for Payer: UnitedHealthcare Medicaid |
$48.51
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$22.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$40.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$20.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.21
|
| Rate for Payer: University Health Alliance Commercial |
$58.93
|
| Rate for Payer: University Health Alliance Commercial |
$32.61
|
| Rate for Payer: University Health Alliance Commercial |
$22.17
|
| Rate for Payer: University Health Alliance Commercial |
$29.37
|
|
|
EPINEPHrine 1 mg/mL PF soln [HHSC]
|
Facility
|
OP
|
$91.30
|
|
|
Service Code
|
HCPCS J0166
|
| Hospital Charge Code |
2500296
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.28 |
| Max. Negotiated Rate |
$88.56 |
| Rate for Payer: AlohaCare Medicaid |
$45.65
|
| Rate for Payer: AlohaCare Medicare |
$45.65
|
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Cash Price |
$59.34
|
| Rate for Payer: Devoted Health Medicare |
$50.22
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$2.28
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$45.65
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$2.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$86.73
|
| Rate for Payer: Health Management Network Commercial |
$77.61
|
| Rate for Payer: Humana Medicare |
$45.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$46.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.65
|
| Rate for Payer: MDX Hawaii PPO |
$88.56
|
| Rate for Payer: Ohana Health Plan Medicaid |
$45.65
|
| Rate for Payer: Ohana Health Plan Medicare |
$45.65
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$45.65
|
| Rate for Payer: University Health Alliance Commercial |
$66.55
|
|
