Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

ROD EXTERN FIX CONNECT 200MM

Facility

$1,279.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$639.50
Max. Negotiated Rate	$1,240.63
Rate for Payer: AlohaCare Medicaid	$639.50
Rate for Payer: AlohaCare Medicare	$972.04
Rate for Payer: Cash Price	$767.40
Rate for Payer: Devoted Health Medicare	$1,074.36
Rate for Payer: Hawaii Medical Service Association Medicare	$972.04
Rate for Payer: Hawaii Western Management Group Commercial	$895.30
Rate for Payer: Health Management Network Commercial	$1,087.15
Rate for Payer: Humana Medicare	$972.04
Rate for Payer: Kaiser Permanente Commercial	$1,151.10
Rate for Payer: Kaiser Permanente Medicaid	$652.29
Rate for Payer: Kaiser Permanente Medicare	$972.04
Rate for Payer: MDX Hawaii PPO	$1,240.63
Rate for Payer: Ohana Health Plan Medicaid	$972.04
Rate for Payer: Ohana Health Plan Medicare	$972.04
Rate for Payer: UnitedHealthcare Medicare	$972.04
Rate for Payer: University Health Alliance Commercial	$716.24

ROD FIBER 8.0X120 395.780

Facility

$735.00

Hospital Revenue Code	272
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$712.95
Rate for Payer: AlohaCare Medicaid	$367.50
Rate for Payer: AlohaCare Medicare	$558.60
Rate for Payer: Cash Price	$441.00
Rate for Payer: Devoted Health Medicare	$617.40
Rate for Payer: Hawaii Medical Service Association Medicare	$558.60
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Humana Medicare	$558.60
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: Kaiser Permanente Medicare	$558.60
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: Ohana Health Plan Medicaid	$558.60
Rate for Payer: Ohana Health Plan Medicare	$558.60
Rate for Payer: UnitedHealthcare Medicare	$558.60
Rate for Payer: University Health Alliance Commercial	$535.74

ROD FIBER 8.0X120 395.780

Facility

$735.00

Hospital Revenue Code	272
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: MDX Hawaii PPO	$712.95

ROD REAMING 3.0, 950MM

Facility

$709.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$602.65
Max. Negotiated Rate	$687.73
Rate for Payer: Cash Price	$425.40
Rate for Payer: Health Management Network Commercial	$602.65
Rate for Payer: Kaiser Permanente Commercial	$638.10
Rate for Payer: MDX Hawaii PPO	$687.73

ROD REAMING 3.0, 950MM

Facility

$709.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$354.50
Max. Negotiated Rate	$687.73
Rate for Payer: AlohaCare Medicaid	$354.50
Rate for Payer: AlohaCare Medicare	$538.84
Rate for Payer: Cash Price	$425.40
Rate for Payer: Devoted Health Medicare	$595.56
Rate for Payer: Hawaii Medical Service Association Medicare	$538.84
Rate for Payer: Hawaii Western Management Group Commercial	$673.55
Rate for Payer: Health Management Network Commercial	$602.65
Rate for Payer: Humana Medicare	$538.84
Rate for Payer: Kaiser Permanente Commercial	$638.10
Rate for Payer: Kaiser Permanente Medicaid	$361.59
Rate for Payer: Kaiser Permanente Medicare	$538.84
Rate for Payer: MDX Hawaii PPO	$687.73
Rate for Payer: Ohana Health Plan Medicaid	$538.84
Rate for Payer: Ohana Health Plan Medicare	$538.84
Rate for Payer: UnitedHealthcare Medicare	$538.84
Rate for Payer: University Health Alliance Commercial	$516.79

RODS 8MM 500MM 5028-8-500

Facility

$1,399.00

Hospital Revenue Code	278
Min. Negotiated Rate	$783.44
Max. Negotiated Rate	$1,357.03
Rate for Payer: Cash Price	$839.40
Rate for Payer: Hawaii Western Management Group Commercial	$979.30
Rate for Payer: Health Management Network Commercial	$1,189.15
Rate for Payer: Kaiser Permanente Commercial	$1,259.10
Rate for Payer: MDX Hawaii PPO	$1,357.03
Rate for Payer: University Health Alliance Commercial	$783.44

RODS 8MM 500MM 5028-8-500

Facility

$1,399.00

Hospital Revenue Code	278
Min. Negotiated Rate	$699.50
Max. Negotiated Rate	$1,357.03
Rate for Payer: AlohaCare Medicaid	$699.50
Rate for Payer: AlohaCare Medicare	$1,063.24
Rate for Payer: Cash Price	$839.40
Rate for Payer: Devoted Health Medicare	$1,175.16
Rate for Payer: Hawaii Medical Service Association Medicare	$1,063.24
Rate for Payer: Hawaii Western Management Group Commercial	$979.30
Rate for Payer: Health Management Network Commercial	$1,189.15
Rate for Payer: Humana Medicare	$1,063.24
Rate for Payer: Kaiser Permanente Commercial	$1,259.10
Rate for Payer: Kaiser Permanente Medicaid	$713.49
Rate for Payer: Kaiser Permanente Medicare	$1,063.24
Rate for Payer: MDX Hawaii PPO	$1,357.03
Rate for Payer: Ohana Health Plan Medicaid	$1,063.24
Rate for Payer: Ohana Health Plan Medicare	$1,063.24
Rate for Payer: UnitedHealthcare Medicare	$1,063.24
Rate for Payer: University Health Alliance Commercial	$783.44

ROD THREADED 115MM 55-10060

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

ROD THREADED 115MM 55-10060

Facility

$225.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$218.25
Rate for Payer: AlohaCare Medicaid	$112.50
Rate for Payer: AlohaCare Medicare	$171.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Devoted Health Medicare	$189.00
Rate for Payer: Hawaii Medical Service Association Medicare	$171.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$171.00
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$114.75
Rate for Payer: Kaiser Permanente Medicare	$171.00
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$171.00
Rate for Payer: Ohana Health Plan Medicare	$171.00
Rate for Payer: UnitedHealthcare Medicare	$171.00
Rate for Payer: University Health Alliance Commercial	$164.00

ROD TL THREADED 100MM 51-10310

Facility

$376.00

Hospital Revenue Code	272
Min. Negotiated Rate	$319.60
Max. Negotiated Rate	$364.72
Rate for Payer: Cash Price	$225.60
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Kaiser Permanente Commercial	$338.40
Rate for Payer: MDX Hawaii PPO	$364.72

ROD TL THREADED 100MM 51-10310

Facility

$376.00

Hospital Revenue Code	272
Min. Negotiated Rate	$188.00
Max. Negotiated Rate	$364.72
Rate for Payer: AlohaCare Medicaid	$188.00
Rate for Payer: AlohaCare Medicare	$285.76
Rate for Payer: Cash Price	$225.60
Rate for Payer: Devoted Health Medicare	$315.84
Rate for Payer: Hawaii Medical Service Association Medicare	$285.76
Rate for Payer: Hawaii Western Management Group Commercial	$357.20
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Humana Medicare	$285.76
Rate for Payer: Kaiser Permanente Commercial	$338.40
Rate for Payer: Kaiser Permanente Medicaid	$191.76
Rate for Payer: Kaiser Permanente Medicare	$285.76
Rate for Payer: MDX Hawaii PPO	$364.72
Rate for Payer: Ohana Health Plan Medicaid	$285.76
Rate for Payer: Ohana Health Plan Medicare	$285.76
Rate for Payer: UnitedHealthcare Medicare	$285.76
Rate for Payer: University Health Alliance Commercial	$274.07

ROD TL THREADED 150MM 51-10550

Facility

$252.00

Hospital Revenue Code	272
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$244.44
Rate for Payer: AlohaCare Medicaid	$126.00
Rate for Payer: AlohaCare Medicare	$191.52
Rate for Payer: Cash Price	$151.20
Rate for Payer: Devoted Health Medicare	$211.68
Rate for Payer: Hawaii Medical Service Association Medicare	$191.52
Rate for Payer: Hawaii Western Management Group Commercial	$239.40
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Humana Medicare	$191.52
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: Kaiser Permanente Medicare	$191.52
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: Ohana Health Plan Medicaid	$191.52
Rate for Payer: Ohana Health Plan Medicare	$191.52
Rate for Payer: UnitedHealthcare Medicare	$191.52
Rate for Payer: University Health Alliance Commercial	$183.68

ROD TL THREADED 150MM 51-10550

Facility

$252.00

Hospital Revenue Code	272
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$226.80
Rate for Payer: MDX Hawaii PPO	$244.44

ROLLER BALL ELECTRODE 24F #RE

Facility

$454.00

Hospital Revenue Code	272
Min. Negotiated Rate	$385.90
Max. Negotiated Rate	$440.38
Rate for Payer: Cash Price	$272.40
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: Kaiser Permanente Commercial	$408.60
Rate for Payer: MDX Hawaii PPO	$440.38

ROLLER BALL ELECTRODE 24F #RE

Facility

$454.00

Hospital Revenue Code	272
Min. Negotiated Rate	$227.00
Max. Negotiated Rate	$440.38
Rate for Payer: AlohaCare Medicaid	$227.00
Rate for Payer: AlohaCare Medicare	$345.04
Rate for Payer: Cash Price	$272.40
Rate for Payer: Devoted Health Medicare	$381.36
Rate for Payer: Hawaii Medical Service Association Medicare	$345.04
Rate for Payer: Hawaii Western Management Group Commercial	$431.30
Rate for Payer: Health Management Network Commercial	$385.90
Rate for Payer: Humana Medicare	$345.04
Rate for Payer: Kaiser Permanente Commercial	$408.60
Rate for Payer: Kaiser Permanente Medicaid	$231.54
Rate for Payer: Kaiser Permanente Medicare	$345.04
Rate for Payer: MDX Hawaii PPO	$440.38
Rate for Payer: Ohana Health Plan Medicaid	$345.04
Rate for Payer: Ohana Health Plan Medicare	$345.04
Rate for Payer: UnitedHealthcare Medicare	$345.04
Rate for Payer: University Health Alliance Commercial	$330.92

ROMIPLOSTIM 250 MCG/0.5ML SC (WET SOLR VIAL) [43093566]

Facility

$1,069.00

Service Code	HCPCS J2796
Hospital Revenue Code	636
Min. Negotiated Rate	$101.05
Max. Negotiated Rate	$1,036.93
Rate for Payer: AlohaCare Medicaid	$534.50
Rate for Payer: AlohaCare Medicaid	$1,902.00
Rate for Payer: AlohaCare Medicare	$2,891.04
Rate for Payer: AlohaCare Medicare	$812.44
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Cash Price	$641.40
Rate for Payer: Cash Price	$641.40
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Devoted Health Medicare	$897.96
Rate for Payer: Devoted Health Medicare	$3,195.36
Rate for Payer: Hawaii Medical Service Association ABD	$101.05
Rate for Payer: Hawaii Medical Service Association ABD	$101.05
Rate for Payer: Hawaii Medical Service Association Medicare	$2,891.04
Rate for Payer: Hawaii Medical Service Association Medicare	$812.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$101.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$101.05
Rate for Payer: Hawaii Western Management Group Commercial	$1,015.55
Rate for Payer: Hawaii Western Management Group Commercial	$3,613.80
Rate for Payer: Health Management Network Commercial	$3,233.40
Rate for Payer: Health Management Network Commercial	$908.65
Rate for Payer: Humana Medicare	$812.44
Rate for Payer: Humana Medicare	$2,891.04
Rate for Payer: Kaiser Permanente Commercial	$962.10
Rate for Payer: Kaiser Permanente Commercial	$3,423.60
Rate for Payer: Kaiser Permanente Medicaid	$1,940.04
Rate for Payer: Kaiser Permanente Medicaid	$545.19
Rate for Payer: Kaiser Permanente Medicare	$812.44
Rate for Payer: Kaiser Permanente Medicare	$2,891.04
Rate for Payer: MDX Hawaii PPO	$1,036.93
Rate for Payer: MDX Hawaii PPO	$3,689.88
Rate for Payer: Ohana Health Plan Medicaid	$2,891.04
Rate for Payer: Ohana Health Plan Medicaid	$812.44
Rate for Payer: Ohana Health Plan Medicare	$812.44
Rate for Payer: Ohana Health Plan Medicare	$2,891.04
Rate for Payer: UnitedHealthcare Medicaid	$2,282.40
Rate for Payer: UnitedHealthcare Medicaid	$641.40
Rate for Payer: UnitedHealthcare Medicare	$812.44
Rate for Payer: UnitedHealthcare Medicare	$2,891.04
Rate for Payer: University Health Alliance Commercial	$779.19
Rate for Payer: University Health Alliance Commercial	$2,772.74

ROMIPLOSTIM 250 MCG/0.5ML SC (WET SOLR VIAL) [43093566]

Facility

$1,069.00

Service Code	HCPCS J2796
Hospital Revenue Code	250
Min. Negotiated Rate	$908.65
Max. Negotiated Rate	$1,036.93
Rate for Payer: Cash Price	$641.40
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Health Management Network Commercial	$908.65
Rate for Payer: Health Management Network Commercial	$3,233.40
Rate for Payer: Kaiser Permanente Commercial	$962.10
Rate for Payer: Kaiser Permanente Commercial	$3,423.60
Rate for Payer: MDX Hawaii PPO	$3,689.88
Rate for Payer: MDX Hawaii PPO	$1,036.93

ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]

Facility

$3,804.00

Service Code	HCPCS J2802
Hospital Revenue Code	636
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$3,689.88
Rate for Payer: AlohaCare Medicaid	$1,902.00
Rate for Payer: AlohaCare Medicare	$2,891.04
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Devoted Health Medicare	$3,195.36
Rate for Payer: Hawaii Medical Service Association ABD	$11.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13.89
Rate for Payer: Hawaii Medical Service Association Medicare	$2,891.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,613.80
Rate for Payer: Health Management Network Commercial	$3,233.40
Rate for Payer: Humana Medicare	$2,891.04
Rate for Payer: Kaiser Permanente Commercial	$3,423.60
Rate for Payer: Kaiser Permanente Medicaid	$1,940.04
Rate for Payer: Kaiser Permanente Medicare	$2,891.04
Rate for Payer: MDX Hawaii PPO	$3,689.88
Rate for Payer: Ohana Health Plan Medicaid	$2,891.04
Rate for Payer: Ohana Health Plan Medicare	$2,891.04
Rate for Payer: UnitedHealthcare Medicaid	$2,282.40
Rate for Payer: UnitedHealthcare Medicare	$2,891.04
Rate for Payer: University Health Alliance Commercial	$2,772.74

ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION [93566]

Facility

$3,804.00

Service Code	HCPCS J2802
Hospital Revenue Code	250
Min. Negotiated Rate	$3,233.40
Max. Negotiated Rate	$3,689.88
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Health Management Network Commercial	$3,233.40
Rate for Payer: Kaiser Permanente Commercial	$3,423.60
Rate for Payer: MDX Hawaii PPO	$3,689.88

ROMIPLOSTIM 500 MCG/ML SC (WET SOLR VIAL) [43093567]

Facility

$7,108.00

Service Code	HCPCS J2796
Hospital Revenue Code	636
Min. Negotiated Rate	$101.05
Max. Negotiated Rate	$6,894.76
Rate for Payer: AlohaCare Medicaid	$3,554.00
Rate for Payer: AlohaCare Medicare	$5,402.08
Rate for Payer: Cash Price	$4,264.80
Rate for Payer: Cash Price	$4,264.80
Rate for Payer: Devoted Health Medicare	$5,970.72
Rate for Payer: Hawaii Medical Service Association ABD	$101.05
Rate for Payer: Hawaii Medical Service Association Medicare	$5,402.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$101.05
Rate for Payer: Hawaii Western Management Group Commercial	$6,752.60
Rate for Payer: Health Management Network Commercial	$6,041.80
Rate for Payer: Humana Medicare	$5,402.08
Rate for Payer: Kaiser Permanente Commercial	$6,397.20
Rate for Payer: Kaiser Permanente Medicaid	$3,625.08
Rate for Payer: Kaiser Permanente Medicare	$5,402.08
Rate for Payer: MDX Hawaii PPO	$6,894.76
Rate for Payer: Ohana Health Plan Medicaid	$5,402.08
Rate for Payer: Ohana Health Plan Medicare	$5,402.08
Rate for Payer: UnitedHealthcare Medicaid	$4,264.80
Rate for Payer: UnitedHealthcare Medicare	$5,402.08
Rate for Payer: University Health Alliance Commercial	$5,181.02

ROMIPLOSTIM 500 MCG/ML SC (WET SOLR VIAL) [43093567]

Facility

$7,108.00

Service Code	HCPCS J2796
Hospital Revenue Code	250
Min. Negotiated Rate	$6,041.80
Max. Negotiated Rate	$6,894.76
Rate for Payer: Cash Price	$4,264.80
Rate for Payer: Health Management Network Commercial	$6,041.80
Rate for Payer: Kaiser Permanente Commercial	$6,397.20
Rate for Payer: MDX Hawaii PPO	$6,894.76

ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]

Facility

$7,108.00

Service Code	HCPCS J2802
Hospital Revenue Code	250
Min. Negotiated Rate	$6,041.80
Max. Negotiated Rate	$6,894.76
Rate for Payer: Cash Price	$4,264.80
Rate for Payer: Health Management Network Commercial	$6,041.80
Rate for Payer: Kaiser Permanente Commercial	$6,397.20
Rate for Payer: MDX Hawaii PPO	$6,894.76

ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION [93567]

Facility

$7,108.00

Service Code	HCPCS J2802
Hospital Revenue Code	636
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$6,894.76
Rate for Payer: AlohaCare Medicaid	$3,554.00
Rate for Payer: AlohaCare Medicare	$5,402.08
Rate for Payer: Cash Price	$4,264.80
Rate for Payer: Cash Price	$4,264.80
Rate for Payer: Devoted Health Medicare	$5,970.72
Rate for Payer: Hawaii Medical Service Association ABD	$11.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13.89
Rate for Payer: Hawaii Medical Service Association Medicare	$5,402.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,752.60
Rate for Payer: Health Management Network Commercial	$6,041.80
Rate for Payer: Humana Medicare	$5,402.08
Rate for Payer: Kaiser Permanente Commercial	$6,397.20
Rate for Payer: Kaiser Permanente Medicaid	$3,625.08
Rate for Payer: Kaiser Permanente Medicare	$5,402.08
Rate for Payer: MDX Hawaii PPO	$6,894.76
Rate for Payer: Ohana Health Plan Medicaid	$5,402.08
Rate for Payer: Ohana Health Plan Medicare	$5,402.08
Rate for Payer: UnitedHealthcare Medicaid	$4,264.80
Rate for Payer: UnitedHealthcare Medicare	$5,402.08
Rate for Payer: University Health Alliance Commercial	$5,181.02

ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE [167848]

Facility

$2,078.00

Service Code	HCPCS J3111
Hospital Revenue Code	636
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$2,015.66
Rate for Payer: AlohaCare Medicaid	$1,039.00
Rate for Payer: AlohaCare Medicare	$1,579.28
Rate for Payer: Cash Price	$1,246.80
Rate for Payer: Cash Price	$1,246.80
Rate for Payer: Devoted Health Medicare	$1,745.52
Rate for Payer: Hawaii Medical Service Association ABD	$12.00
Rate for Payer: Hawaii Medical Service Association Commercial	$15.24
Rate for Payer: Hawaii Medical Service Association Medicare	$1,579.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.10
Rate for Payer: Health Management Network Commercial	$1,766.30
Rate for Payer: Humana Medicare	$1,579.28
Rate for Payer: Kaiser Permanente Commercial	$1,870.20
Rate for Payer: Kaiser Permanente Medicaid	$1,059.78
Rate for Payer: Kaiser Permanente Medicare	$1,579.28
Rate for Payer: MDX Hawaii PPO	$2,015.66
Rate for Payer: Ohana Health Plan Medicaid	$1,579.28
Rate for Payer: Ohana Health Plan Medicare	$1,579.28
Rate for Payer: UnitedHealthcare Medicaid	$1,246.80
Rate for Payer: UnitedHealthcare Medicare	$1,579.28
Rate for Payer: University Health Alliance Commercial	$1,514.65

ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE [167848]

Facility

$2,078.00

Service Code	HCPCS J3111
Hospital Revenue Code	250
Min. Negotiated Rate	$1,766.30
Max. Negotiated Rate	$2,015.66
Rate for Payer: Cash Price	$1,246.80
Rate for Payer: Health Management Network Commercial	$1,766.30
Rate for Payer: Kaiser Permanente Commercial	$1,870.20
Rate for Payer: MDX Hawaii PPO	$2,015.66

Know your out-of-pocket cost for care.

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