Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

440437550 NG TUBE INSERTION, DX INC DRUG ADMIN ED

Facility

$670.00

Service Code	HCPCS 43755
Hospital Charge Code	440437550
Hospital Revenue Code	450
Min. Negotiated Rate	$569.50
Max. Negotiated Rate	$649.90
Rate for Payer: Cash Price	$435.50
Rate for Payer: Health Management Network Commercial	$569.50
Rate for Payer: Kaiser Permanente Commercial	$603.00
Rate for Payer: MDX Hawaii PPO	$649.90

440437550 NG TUBE INSERTION, DX INC DRUG ADMIN ED

Facility

$670.00

Service Code	HCPCS 43755
Hospital Charge Code	440437550
Hospital Revenue Code	450
Min. Negotiated Rate	$281.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$335.00
Rate for Payer: AlohaCare Medicare	$281.40
Rate for Payer: Cash Price	$435.50
Rate for Payer: Cash Price	$435.50
Rate for Payer: Cash Price	$435.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$616.40
Rate for Payer: Devoted Health Medicare	$281.40
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$281.40
Rate for Payer: Hawaii Western Management Group Commercial	$636.50
Rate for Payer: Health Management Network Commercial	$569.50
Rate for Payer: Humana Medicare	$281.40
Rate for Payer: Kaiser Permanente Commercial	$603.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$281.40
Rate for Payer: MDX Hawaii PPO	$649.90
Rate for Payer: Ohana Health Plan Medicaid	$281.40
Rate for Payer: Ohana Health Plan Medicare	$281.40
Rate for Payer: UnitedHealthcare Medicare	$281.40
Rate for Payer: University Health Alliance Commercial	$488.36

440445000 INTRODUCE LONG GI TUBE ED Charge

Facility

$2,383.00

Service Code	HCPCS 44500
Hospital Charge Code	440445000
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$2,311.51
Rate for Payer: AlohaCare Medicaid	$1,191.50
Rate for Payer: AlohaCare Medicare	$1,000.86
Rate for Payer: Cash Price	$1,548.95
Rate for Payer: Cash Price	$1,548.95
Rate for Payer: Cash Price	$1,548.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,192.36
Rate for Payer: Devoted Health Medicare	$1,000.86
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.86
Rate for Payer: Hawaii Western Management Group Commercial	$2,263.85
Rate for Payer: Health Management Network Commercial	$2,025.55
Rate for Payer: Humana Medicare	$1,000.86
Rate for Payer: Kaiser Permanente Commercial	$2,144.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,000.86
Rate for Payer: MDX Hawaii PPO	$2,311.51
Rate for Payer: Ohana Health Plan Medicaid	$1,000.86
Rate for Payer: Ohana Health Plan Medicare	$1,000.86
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,000.86
Rate for Payer: University Health Alliance Commercial	$1,736.97

440445000 INTRODUCE LONG GI TUBE ED Charge

Facility

$2,383.00

Service Code	HCPCS 44500
Hospital Charge Code	440445000
Hospital Revenue Code	450
Min. Negotiated Rate	$2,025.55
Max. Negotiated Rate	$2,311.51
Rate for Payer: Cash Price	$1,548.95
Rate for Payer: Health Management Network Commercial	$2,025.55
Rate for Payer: Kaiser Permanente Commercial	$2,144.70
Rate for Payer: MDX Hawaii PPO	$2,311.51

440594100 VAG DELIVERY ONLY PPC ED Charge

Facility

$10,752.00

Service Code	HCPCS 59410
Hospital Charge Code	440594100
Hospital Revenue Code	450
Min. Negotiated Rate	$9,139.20
Max. Negotiated Rate	$10,429.44
Rate for Payer: Cash Price	$6,988.80
Rate for Payer: Health Management Network Commercial	$9,139.20
Rate for Payer: Kaiser Permanente Commercial	$9,676.80
Rate for Payer: MDX Hawaii PPO	$10,429.44

440594100 VAG DELIVERY ONLY PPC ED Charge

Facility

$10,752.00

Service Code	HCPCS 59410
Hospital Charge Code	440594100
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$10,429.44
Rate for Payer: AlohaCare Medicaid	$5,376.00
Rate for Payer: AlohaCare Medicare	$4,515.84
Rate for Payer: Cash Price	$6,988.80
Rate for Payer: Cash Price	$6,988.80
Rate for Payer: Cash Price	$6,988.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9,891.84
Rate for Payer: Devoted Health Medicare	$4,515.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,515.84
Rate for Payer: Hawaii Western Management Group Commercial	$10,214.40
Rate for Payer: Health Management Network Commercial	$9,139.20
Rate for Payer: Humana Medicare	$4,515.84
Rate for Payer: Kaiser Permanente Commercial	$9,676.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,515.84
Rate for Payer: MDX Hawaii PPO	$10,429.44
Rate for Payer: Ohana Health Plan Medicaid	$4,515.84
Rate for Payer: Ohana Health Plan Medicare	$4,515.84
Rate for Payer: UnitedHealthcare Medicare	$4,515.84
Rate for Payer: University Health Alliance Commercial	$7,837.13

440596120 VAG DELIVERY AFTER C SECTION ED Charge

Facility

$7,021.00

Service Code	HCPCS 59612
Hospital Charge Code	440596120
Hospital Revenue Code	450
Min. Negotiated Rate	$5,967.85
Max. Negotiated Rate	$6,810.37
Rate for Payer: Cash Price	$4,563.65
Rate for Payer: Health Management Network Commercial	$5,967.85
Rate for Payer: Kaiser Permanente Commercial	$6,318.90
Rate for Payer: MDX Hawaii PPO	$6,810.37

440596120 VAG DELIVERY AFTER C SECTION ED Charge

Facility

$7,021.00

Service Code	HCPCS 59612
Hospital Charge Code	440596120
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$6,810.37
Rate for Payer: AlohaCare Medicaid	$3,510.50
Rate for Payer: AlohaCare Medicare	$2,948.82
Rate for Payer: Cash Price	$4,563.65
Rate for Payer: Cash Price	$4,563.65
Rate for Payer: Cash Price	$4,563.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$6,459.32
Rate for Payer: Devoted Health Medicare	$2,948.82
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,948.82
Rate for Payer: Hawaii Western Management Group Commercial	$6,669.95
Rate for Payer: Health Management Network Commercial	$5,967.85
Rate for Payer: Humana Medicare	$2,948.82
Rate for Payer: Kaiser Permanente Commercial	$6,318.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,948.82
Rate for Payer: MDX Hawaii PPO	$6,810.37
Rate for Payer: Ohana Health Plan Medicaid	$2,948.82
Rate for Payer: Ohana Health Plan Medicare	$2,948.82
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,948.82
Rate for Payer: University Health Alliance Commercial	$5,117.61

440690200 DRAINAGE EXT AUDITORY CANAL AB ED Charge

Facility

$816.00

Service Code	HCPCS 69020
Hospital Charge Code	440690200
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$408.00
Rate for Payer: AlohaCare Medicare	$342.72
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$750.72
Rate for Payer: Devoted Health Medicare	$342.72
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$342.72
Rate for Payer: Hawaii Western Management Group Commercial	$775.20
Rate for Payer: Health Management Network Commercial	$693.60
Rate for Payer: Humana Medicare	$342.72
Rate for Payer: Kaiser Permanente Commercial	$734.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$342.72
Rate for Payer: MDX Hawaii PPO	$791.52
Rate for Payer: Ohana Health Plan Medicaid	$342.72
Rate for Payer: Ohana Health Plan Medicare	$342.72
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$342.72
Rate for Payer: University Health Alliance Commercial	$594.78

440690200 DRAINAGE EXT AUDITORY CANAL AB ED Charge

Facility

$816.00

Service Code	HCPCS 69020
Hospital Charge Code	440690200
Hospital Revenue Code	450
Min. Negotiated Rate	$693.60
Max. Negotiated Rate	$791.52
Rate for Payer: Cash Price	$530.40
Rate for Payer: Health Management Network Commercial	$693.60
Rate for Payer: Kaiser Permanente Commercial	$734.40
Rate for Payer: MDX Hawaii PPO	$791.52

7 STANDARD FLD RETINAL PHOTO W/EVC RTNOPTHY

Professional

Both

$0.01

Service Code	HCPCS 2024F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

7 STANDARD FLD RETINAL PHOTO W/O EVC RTNOPTHY

Professional

Both

$0.01

Service Code	HCPCS 2025F
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$290.48
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

96360 IV HYDRATION 1ST HR Charge

Facility

$716.00

Service Code	HCPCS 96360
Hospital Charge Code	317963600
Hospital Revenue Code	260
Min. Negotiated Rate	$608.60
Max. Negotiated Rate	$694.52
Rate for Payer: Cash Price	$465.40
Rate for Payer: Health Management Network Commercial	$608.60
Rate for Payer: Kaiser Permanente Commercial	$644.40
Rate for Payer: MDX Hawaii PPO	$694.52

96360 IV HYDRATION 1ST HR Charge

Facility

$716.00

Service Code	HCPCS 96360
Hospital Charge Code	317963600
Hospital Revenue Code	260
Min. Negotiated Rate	$38.10
Max. Negotiated Rate	$694.52
Rate for Payer: AlohaCare Medicaid	$358.00
Rate for Payer: AlohaCare Medicare	$300.72
Rate for Payer: Cash Price	$465.40
Rate for Payer: Cash Price	$465.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$658.72
Rate for Payer: Devoted Health Medicare	$300.72
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$300.72
Rate for Payer: Hawaii Western Management Group Commercial	$680.20
Rate for Payer: Health Management Network Commercial	$608.60
Rate for Payer: Humana Medicare	$300.72
Rate for Payer: Kaiser Permanente Commercial	$644.40
Rate for Payer: Kaiser Permanente Medicaid	$365.16
Rate for Payer: Kaiser Permanente Medicare	$300.72
Rate for Payer: MDX Hawaii PPO	$694.52
Rate for Payer: Ohana Health Plan Medicaid	$300.72
Rate for Payer: Ohana Health Plan Medicare	$300.72
Rate for Payer: UnitedHealthcare Medicaid	$38.10
Rate for Payer: UnitedHealthcare Medicare	$300.72
Rate for Payer: University Health Alliance Commercial	$521.89

96365 IV INFUSION 1ST HR Charge

Facility

$716.00

Service Code	HCPCS 96365
Hospital Charge Code	317963650
Hospital Revenue Code	260
Min. Negotiated Rate	$608.60
Max. Negotiated Rate	$694.52
Rate for Payer: Cash Price	$465.40
Rate for Payer: Health Management Network Commercial	$608.60
Rate for Payer: Kaiser Permanente Commercial	$644.40
Rate for Payer: MDX Hawaii PPO	$694.52

96365 IV INFUSION 1ST HR Charge

Facility

$716.00

Service Code	HCPCS 96365
Hospital Charge Code	317963650
Hospital Revenue Code	260
Min. Negotiated Rate	$46.51
Max. Negotiated Rate	$694.52
Rate for Payer: AlohaCare Medicaid	$358.00
Rate for Payer: AlohaCare Medicare	$300.72
Rate for Payer: Cash Price	$465.40
Rate for Payer: Cash Price	$465.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$658.72
Rate for Payer: Devoted Health Medicare	$300.72
Rate for Payer: Hawaii Medical Service Association Commercial	$314.10
Rate for Payer: Hawaii Medical Service Association Medicare	$300.72
Rate for Payer: Hawaii Western Management Group Commercial	$680.20
Rate for Payer: Health Management Network Commercial	$608.60
Rate for Payer: Humana Medicare	$300.72
Rate for Payer: Kaiser Permanente Commercial	$644.40
Rate for Payer: Kaiser Permanente Medicaid	$365.16
Rate for Payer: Kaiser Permanente Medicare	$300.72
Rate for Payer: MDX Hawaii PPO	$694.52
Rate for Payer: Ohana Health Plan Medicaid	$300.72
Rate for Payer: Ohana Health Plan Medicare	$300.72
Rate for Payer: UnitedHealthcare Medicaid	$46.51
Rate for Payer: UnitedHealthcare Medicare	$300.72
Rate for Payer: University Health Alliance Commercial	$521.89

96366 IV INFUSION EA ADDL HR Charge

Facility

$153.00

Service Code	HCPCS 96366
Hospital Charge Code	317963660
Hospital Revenue Code	260
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: MDX Hawaii PPO	$148.41

96366 IV INFUSION EA ADDL HR Charge

Facility

$153.00

Service Code	HCPCS 96366
Hospital Charge Code	317963660
Hospital Revenue Code	260
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$76.50
Rate for Payer: AlohaCare Medicare	$64.26
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$140.76
Rate for Payer: Devoted Health Medicare	$64.26
Rate for Payer: Hawaii Medical Service Association Commercial	$69.15
Rate for Payer: Hawaii Medical Service Association Medicare	$64.26
Rate for Payer: Hawaii Western Management Group Commercial	$145.35
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$64.26
Rate for Payer: Kaiser Permanente Commercial	$137.70
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$64.26
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$64.26
Rate for Payer: Ohana Health Plan Medicare	$64.26
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$64.26
Rate for Payer: University Health Alliance Commercial	$111.52

96367 IV INF ADDL SEQUNT 1ST HR Charge

Facility

$168.00

Service Code	HCPCS 96367
Hospital Charge Code	317963670
Hospital Revenue Code	260
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: MDX Hawaii PPO	$162.96

96367 IV INF ADDL SEQUNT 1ST HR Charge

Facility

$168.00

Service Code	HCPCS 96367
Hospital Charge Code	317963670
Hospital Revenue Code	260
Min. Negotiated Rate	$23.03
Max. Negotiated Rate	$162.96
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$70.56
Rate for Payer: Cash Price	$109.20
Rate for Payer: Cash Price	$109.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$154.56
Rate for Payer: Devoted Health Medicare	$70.56
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$70.56
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Humana Medicare	$70.56
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicare	$70.56
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: Ohana Health Plan Medicaid	$70.56
Rate for Payer: Ohana Health Plan Medicare	$70.56
Rate for Payer: UnitedHealthcare Medicaid	$23.03
Rate for Payer: UnitedHealthcare Medicare	$70.56
Rate for Payer: University Health Alliance Commercial	$122.46

96368 IV INFUSION CONCURRENT Charge

Facility

$130.00

Service Code	HCPCS 96368
Hospital Charge Code	317963680
Hospital Revenue Code	260
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$126.10
Rate for Payer: AlohaCare Medicaid	$65.00
Rate for Payer: AlohaCare Medicare	$54.60
Rate for Payer: Cash Price	$84.50
Rate for Payer: Cash Price	$84.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$119.60
Rate for Payer: Devoted Health Medicare	$54.60
Rate for Payer: Hawaii Medical Service Association Medicare	$54.60
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Humana Medicare	$54.60
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: Kaiser Permanente Medicare	$54.60
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: Ohana Health Plan Medicaid	$54.60
Rate for Payer: Ohana Health Plan Medicare	$54.60
Rate for Payer: UnitedHealthcare Medicaid	$13.30
Rate for Payer: UnitedHealthcare Medicare	$54.60
Rate for Payer: University Health Alliance Commercial	$94.76

96368 IV INFUSION CONCURRENT Charge

Facility

$130.00

Service Code	HCPCS 96368
Hospital Charge Code	317963680
Hospital Revenue Code	260
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$84.50
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: MDX Hawaii PPO	$126.10

96372 INJ SUBQ OR IM Charge

Facility

$168.00

Service Code	HCPCS 96372
Hospital Charge Code	317963720
Hospital Revenue Code	260
Min. Negotiated Rate	$13.87
Max. Negotiated Rate	$162.96
Rate for Payer: AlohaCare Medicaid	$84.00
Rate for Payer: AlohaCare Medicare	$70.56
Rate for Payer: Cash Price	$109.20
Rate for Payer: Cash Price	$109.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$154.56
Rate for Payer: Devoted Health Medicare	$70.56
Rate for Payer: Hawaii Medical Service Association Commercial	$106.33
Rate for Payer: Hawaii Medical Service Association Medicare	$70.56
Rate for Payer: Hawaii Western Management Group Commercial	$159.60
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Humana Medicare	$70.56
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$85.68
Rate for Payer: Kaiser Permanente Medicare	$70.56
Rate for Payer: MDX Hawaii PPO	$162.96
Rate for Payer: Ohana Health Plan Medicaid	$70.56
Rate for Payer: Ohana Health Plan Medicare	$70.56
Rate for Payer: UnitedHealthcare Medicaid	$13.87
Rate for Payer: UnitedHealthcare Medicare	$70.56
Rate for Payer: University Health Alliance Commercial	$122.46

96372 INJ SUBQ OR IM Charge

Facility

$168.00

Service Code	HCPCS 96372
Hospital Charge Code	317963720
Hospital Revenue Code	260
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$162.96
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$142.80
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: MDX Hawaii PPO	$162.96

96373 INJ INTRA-ARTERIAL Charge

Facility

$407.00

Service Code	HCPCS 96373
Hospital Charge Code	317963730
Hospital Revenue Code	260
Min. Negotiated Rate	$345.95
Max. Negotiated Rate	$394.79
Rate for Payer: Cash Price	$264.55
Rate for Payer: Health Management Network Commercial	$345.95
Rate for Payer: Kaiser Permanente Commercial	$366.30
Rate for Payer: MDX Hawaii PPO	$394.79

Know your out-of-pocket cost for care.

All Charges