PA Medical Assistance: disclosed hospital rates

iDirect answer

Based on the published hospital price files, PA Medical Assistance appears in disclosed negotiated rates across 1 hospital and 51 services. This is public hospital price transparency data, not a guaranteed estimate of your bill.

Actual patient responsibility may vary based on your insurance plan, deductible, coinsurance, network status, diagnosis, setting, bundled services, clinical circumstances, and hospital billing practices.

51 prices shown.

Service	Hospital	Code	List price	Cash price	Negotiated range	Allowed (median)
ALTEPLASE TPA 1 MG ML SYRINGE EVD CLEARANCE Inpatient	The Hospital of the University of Pennsylvania	J2997 HCPCS	$255	$255	$43.09 – $255	—
AMINOCAPROIC ACID IVPB 10G 100ML NSS CNR Inpatient	The Hospital of the University of Pennsylvania	J0290 HCPCS	$75.00	$75.00	$12.67 – $75.00	—
BUPIVACAINE 0 05 FENTANYL 2 MCG ML EPIDURAL 250 Inpatient	The Hospital of the University of Pennsylvania	102157 CDM	$52.00	$52.00	$8.79 – $52.00	—
BUPIVACAINE 0 1 EPIDURAL 250ML NSS CNR Inpatient	The Hospital of the University of Pennsylvania	102168 CDM	$33.00	$33.00	$5.58 – $33.00	—
CEFAZOLIN 100 MG ML ANESTHESIA PPMC Inpatient	The Hospital of the University of Pennsylvania	J0690 HCPCS	$2.00	$2.00	$0.34 – $2.00	—
CIDOFOVIR 15 MG ML IV SOLN Inpatient	The Hospital of the University of Pennsylvania	J0740 HCPCS	$533	$533	$90.08 – $533	—
CLOG ZAPPER Inpatient	The Hospital of the University of Pennsylvania	100450 CDM	$86.00	$86.00	$14.53 – $86.00	—
CLONIDINE 0 01 MG ML ORAL SUSP ORD Inpatient	The Hospital of the University of Pennsylvania	17306 CDM	$71.00	$71.00	$12.00 – $71.00	—
CNR TAC 7 TOP SOLN REPACKAGE PHASE II 5 ML Inpatient	The Hospital of the University of Pennsylvania	99 CDM	$615	$615	$104 – $615	—
COAPTITE IMPLANT INJECTION Inpatient	The Hospital of the University of Pennsylvania	102005 CDM	$30.00	$30.00	$5.07 – $30.00	—
DEXAMETHASONE IVPB 10MG 50ML NSS CNR Inpatient	The Hospital of the University of Pennsylvania	J1100 HCPCS	$23.00	$23.00	$3.89 – $23.00	—
DEXAMETHASONE IVPB 12MG 50ML NSS CNR Inpatient	The Hospital of the University of Pennsylvania	J1100 HCPCS	$24.00	$24.00	$4.06 – $24.00	—
DEXAMETHASONE IVPB 8MG 50ML NSS CNR Inpatient	The Hospital of the University of Pennsylvania	J1100 HCPCS	$22.00	$22.00	$3.72 – $22.00	—
DEXTROSE 5 FLUSH SYRINGE 20 ML CNR NON INTERO Inpatient	The Hospital of the University of Pennsylvania	102700 CDM	$7.00	$7.00	$1.18 – $7.00	—
ENDOSCOPIC INK Inpatient	The Hospital of the University of Pennsylvania	101922 CDM	$30.00	$30.00	$5.07 – $30.00	—
EPOPROSTENOL FLOLAN 1 5 MG IN 50 ML INHALATION S Inpatient	The Hospital of the University of Pennsylvania	J1325 HCPCS	$170	$170	$28.73 – $170	—
FENTANYL PCA 250 MCG 25ML CNR Inpatient	The Hospital of the University of Pennsylvania	J3010 HCPCS	$1,080	$1,080	$183 – $1,080	—
FLOSEAL HEMOSTATIC MATRIX Inpatient	The Hospital of the University of Pennsylvania	102207 CDM	$4,299	$4,299	$727 – $4,299	—
GLYCERIN 50 INTRAARTERIAL PUMP INJECTION 30 ML B Inpatient	The Hospital of the University of Pennsylvania	102619 CDM	$58.00	$58.00	$9.80 – $58.00	—
HEPARIN INFUSION 50 UNITS 100ML 0 45 NSS NEO A Inpatient	The Hospital of the University of Pennsylvania	102199 CDM	$90.00	$90.00	$15.21 – $90.00	—
HYDROCODONE BIT HOMATROP MBR 5 1 5 MG 5ML PO SOLN Inpatient	The Hospital of the University of Pennsylvania	102125 CDM	$3.00	$3.00	$0.51 – $3.00	—
HYDROMORPHONE PCA HIGH CONCENTRATION 150 MG 30ML Inpatient	The Hospital of the University of Pennsylvania	J1171 HCPCS	$204	$204	$34.48 – $204	—
KETAMINE HCL 10 MG ML INJECTION SOLN WRAPPER Inpatient	The Hospital of the University of Pennsylvania	102001 CDM	$150	$150	$25.35 – $150	—
LIDOCAINE 4 TETRACAINE 0 5 TOP GEL ORD PPMC Inpatient	The Hospital of the University of Pennsylvania	101301 CDM	$65.00	$65.00	$10.98 – $65.00	—
LIDOCAINE HCL 4 EX SOLN Inpatient	The Hospital of the University of Pennsylvania	102002 CDM	$2.00	$2.00	$0.34 – $2.00	—