Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

REMIFENTANIL HCL 2 MG/2ML IV (WET SOLR VIAL) [43018400]

Facility

$243.00

Service Code	NDC 72078003500
Hospital Revenue Code	250
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: MDX Hawaii PPO	$235.71

REMIFENTANIL HCL 2 MG/2ML IV (WET SOLR VIAL) [43018400]

Facility

$243.00

Service Code	NDC 72078003502
Hospital Revenue Code	250
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$145.80
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: MDX Hawaii PPO	$235.71

REMIFENTANIL HCL 2 MG/2ML IV (WET SOLR VIAL) [43018400]

Facility

$221.00

Service Code	NDC 00143939210
Hospital Revenue Code	250
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37

REMIFENTANIL HCL 2 MG/2ML IV (WET SOLR VIAL) [43018400]

Facility

$221.00

Service Code	NDC 00143939201
Hospital Revenue Code	250
Min. Negotiated Rate	$187.85
Max. Negotiated Rate	$214.37
Rate for Payer: Cash Price	$132.60
Rate for Payer: Health Management Network Commercial	$187.85
Rate for Payer: MDX Hawaii PPO	$214.37

REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION

Facility

$26,933.17

Service Code	CPT 53447
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$26,933.17
Rate for Payer: AlohaCare Medicaid	$24,484.70
Rate for Payer: AlohaCare Medicare	$24,484.70
Rate for Payer: Devoted Health Medicare	$26,933.17
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$24,484.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$24,484.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$24,484.70
Rate for Payer: Ohana Health Plan Medicaid	$26,933.17
Rate for Payer: Ohana Health Plan Medicare	$24,484.70
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$24,484.70

REMOVAL DEVICE POLYP

Facility

$324.00

Hospital Revenue Code	272
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$194.40
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: MDX Hawaii PPO	$314.28

REMOVAL DEVICE POLYP

Facility

$324.00

Hospital Revenue Code	272
Min. Negotiated Rate	$165.24
Max. Negotiated Rate	$314.28
Rate for Payer: Cash Price	$194.40
Rate for Payer: Hawaii Western Management Group Commercial	$307.80
Rate for Payer: Health Management Network Commercial	$275.40
Rate for Payer: Kaiser Permanente Commercial	$204.12
Rate for Payer: Kaiser Permanente Medicaid	$165.24
Rate for Payer: MDX Hawaii PPO	$314.28
Rate for Payer: University Health Alliance Commercial	$236.16

REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH GENERAL ANESTHESIA

Facility

$5,509.00

Service Code	CPT 69205
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$4,035.20

REMOVAL IMPACTED CERUMEN REQUIRING INSTRUMENTATION, UNILATERAL

Facility

$5,160.40

Service Code	CPT 69210
Hospital Revenue Code	360
Min. Negotiated Rate	$22.98
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$69.69
Rate for Payer: AlohaCare Medicare	$69.69
Rate for Payer: Devoted Health Medicare	$76.66
Rate for Payer: Hawaii Medical Service Association Commercial	$87.11
Rate for Payer: Hawaii Medical Service Association Medicare	$69.69
Rate for Payer: Humana Medicare	$69.69
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$69.69
Rate for Payer: Ohana Health Plan Medicaid	$76.66
Rate for Payer: Ohana Health Plan Medicare	$69.69
Rate for Payer: UnitedHealthcare Medicaid	$22.98
Rate for Payer: UnitedHealthcare Medicare	$69.69
Rate for Payer: University Health Alliance Commercial	$5,160.40

REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT

Facility

$2,837.00

Service Code	CPT 11982
Hospital Revenue Code	360
Min. Negotiated Rate	$99.44
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$527.74
Rate for Payer: AlohaCare Medicare	$527.74
Rate for Payer: Devoted Health Medicare	$580.51
Rate for Payer: Hawaii Medical Service Association Commercial	$659.67
Rate for Payer: Hawaii Medical Service Association Medicare	$527.74
Rate for Payer: Humana Medicare	$527.74
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$527.74
Rate for Payer: Ohana Health Plan Medicaid	$580.51
Rate for Payer: Ohana Health Plan Medicare	$527.74
Rate for Payer: UnitedHealthcare Medicaid	$99.44
Rate for Payer: UnitedHealthcare Medicare	$527.74

REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER ANESTHESIA

Facility

$2,837.00

Service Code	CPT 45915
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,413.65
Rate for Payer: AlohaCare Medicare	$1,413.65
Rate for Payer: Devoted Health Medicare	$1,555.02
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,413.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,413.65
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,413.65
Rate for Payer: Ohana Health Plan Medicaid	$1,555.02
Rate for Payer: Ohana Health Plan Medicare	$1,413.65
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,413.65

REMOVAL OF FOREIGN BODY, FOOT; DEEP

Facility

$5,509.00

Service Code	CPT 28192
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; SIMPLE

Facility

$2,837.00

Service Code	CPT 20520
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,951.11

REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY

Facility

$4,856.10

Service Code	CPT 33241
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,856.10
Rate for Payer: AlohaCare Medicaid	$4,414.64
Rate for Payer: AlohaCare Medicare	$4,414.64
Rate for Payer: Devoted Health Medicare	$4,856.10
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,414.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$4,414.64
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,414.64
Rate for Payer: Ohana Health Plan Medicaid	$4,856.10
Rate for Payer: Ohana Health Plan Medicare	$4,414.64
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,414.64

REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE)

Facility

$6,743.44

Service Code	CPT 20680
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$6,743.44

REMOVAL OF IMPLANT FROM FINGER OR HAND

Facility

$5,160.40

Service Code	CPT 26320
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,951.11
Rate for Payer: University Health Alliance Commercial	$5,160.40

REMOVAL OF INTACT BREAST IMPLANT

Facility

$5,509.00

Service Code	CPT 19328
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,625.48
Rate for Payer: AlohaCare Medicare	$4,625.48
Rate for Payer: Devoted Health Medicare	$5,088.03
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,625.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,625.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,625.48
Rate for Payer: Ohana Health Plan Medicaid	$5,088.03
Rate for Payer: Ohana Health Plan Medicare	$4,625.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,625.48
Rate for Payer: University Health Alliance Commercial	$4,035.20

REMOVAL OF INTRAUTERINE DEVICE (IUD)

Facility

$4,035.20

Service Code	CPT 58301
Hospital Revenue Code	360
Min. Negotiated Rate	$47.15
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$359.99
Rate for Payer: AlohaCare Medicare	$359.99
Rate for Payer: Devoted Health Medicare	$395.99
Rate for Payer: Hawaii Medical Service Association Commercial	$449.99
Rate for Payer: Hawaii Medical Service Association Medicare	$359.99
Rate for Payer: Humana Medicare	$359.99
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$359.99
Rate for Payer: Ohana Health Plan Medicaid	$395.99
Rate for Payer: Ohana Health Plan Medicare	$359.99
Rate for Payer: UnitedHealthcare Medicaid	$47.15
Rate for Payer: UnitedHealthcare Medicare	$359.99
Rate for Payer: University Health Alliance Commercial	$4,035.20

REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT)

Facility

$2,837.00

Service Code	CPT 50389
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: Ohana Health Plan Medicaid	$906.12
Rate for Payer: AlohaCare Medicaid	$823.75
Rate for Payer: AlohaCare Medicare	$823.75
Rate for Payer: Devoted Health Medicare	$906.12
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$823.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$823.75
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$823.75
Rate for Payer: Ohana Health Plan Medicare	$823.75
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$823.75

REMOVAL OF RUPTURED BREAST IMPLANT, INCLUDING IMPLANT CONTENTS (EG, SALINE, SILICONE GEL)

Facility

$5,509.00

Service Code	CPT 19330
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$4,625.48
Rate for Payer: AlohaCare Medicare	$4,625.48
Rate for Payer: Devoted Health Medicare	$5,088.03
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,625.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$4,625.48
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,625.48
Rate for Payer: Ohana Health Plan Medicaid	$5,088.03
Rate for Payer: Ohana Health Plan Medicare	$4,625.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,625.48
Rate for Payer: University Health Alliance Commercial	$4,035.20

REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS

Facility

$2,837.00

Service Code	CPT 11200
Hospital Revenue Code	360
Min. Negotiated Rate	$37.52
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$37.52
Rate for Payer: UnitedHealthcare Medicare	$237.02

REMOVAL OF TISSUE EXPANDER WITHOUT INSERTION OF IMPLANT

Facility

$5,509.00

Service Code	CPT 11971
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$4,035.20

REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION

Facility

$2,837.00

Service Code	CPT 36590
Hospital Revenue Code	360
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$1,859.62
Rate for Payer: AlohaCare Medicare	$1,859.62
Rate for Payer: Devoted Health Medicare	$2,045.58
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,859.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$1,859.62
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,859.62
Rate for Payer: Ohana Health Plan Medicaid	$2,045.58
Rate for Payer: Ohana Health Plan Medicare	$1,859.62
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,859.62

REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP

Facility

$2,837.00

Service Code	CPT 36589
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$741.06
Rate for Payer: AlohaCare Medicare	$741.06
Rate for Payer: Devoted Health Medicare	$815.17
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$741.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Humana Medicare	$741.06
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$741.06
Rate for Payer: Ohana Health Plan Medicaid	$815.17
Rate for Payer: Ohana Health Plan Medicare	$741.06
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$741.06

REMOVAL OF TUNNELED INTRAPERITONEAL CATHETER

Facility

$5,509.00

Service Code	CPT 49422
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,730.07
Rate for Payer: AlohaCare Medicare	$3,730.07
Rate for Payer: Devoted Health Medicare	$4,103.08
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,730.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,730.07
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,730.07
Rate for Payer: Ohana Health Plan Medicaid	$4,103.08
Rate for Payer: Ohana Health Plan Medicare	$3,730.07
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,730.07

Know your out-of-pocket cost for care.

All Charges