Kau Hospital

All Charges

Charge

Type

Setting

Price

VIABAHN BX BALLOON BXA085901A

Facility

$8,106.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,512.86
Max. Negotiated Rate	$7,862.82
Rate for Payer: AlohaCare Medicaid	$4,053.00
Rate for Payer: AlohaCare Medicare	$2,512.86
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Devoted Health Medicare	$2,756.04
Rate for Payer: Hawaii Medical Service Association Medicare	$2,512.86
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: Humana Medicare	$2,512.86
Rate for Payer: Kaiser Permanente Commercial	$7,295.40
Rate for Payer: Kaiser Permanente Medicaid	$4,134.06
Rate for Payer: Kaiser Permanente Medicare	$2,512.86
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: Ohana Health Plan Medicaid	$2,512.86
Rate for Payer: Ohana Health Plan Medicare	$2,512.86
Rate for Payer: UnitedHealthcare Medicare	$2,512.86
Rate for Payer: University Health Alliance Commercial	$4,539.36

VIABAHN BX BALLOON BXAL087901A

Facility

$8,894.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,980.64
Max. Negotiated Rate	$8,627.18
Rate for Payer: Cash Price	$5,336.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,225.80
Rate for Payer: Health Management Network Commercial	$7,559.90
Rate for Payer: Kaiser Permanente Commercial	$8,004.60
Rate for Payer: MDX Hawaii PPO	$8,627.18
Rate for Payer: University Health Alliance Commercial	$4,980.64

VIABAHN BX BALLOON BXAL087901A

Facility

$8,894.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,757.14
Max. Negotiated Rate	$8,627.18
Rate for Payer: AlohaCare Medicaid	$4,447.00
Rate for Payer: AlohaCare Medicare	$2,757.14
Rate for Payer: Cash Price	$5,336.40
Rate for Payer: Devoted Health Medicare	$3,023.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,757.14
Rate for Payer: Hawaii Western Management Group Commercial	$6,225.80
Rate for Payer: Health Management Network Commercial	$7,559.90
Rate for Payer: Humana Medicare	$2,757.14
Rate for Payer: Kaiser Permanente Commercial	$8,004.60
Rate for Payer: Kaiser Permanente Medicaid	$4,535.94
Rate for Payer: Kaiser Permanente Medicare	$2,757.14
Rate for Payer: MDX Hawaii PPO	$8,627.18
Rate for Payer: Ohana Health Plan Medicaid	$2,757.14
Rate for Payer: Ohana Health Plan Medicare	$2,757.14
Rate for Payer: UnitedHealthcare Medicare	$2,757.14
Rate for Payer: University Health Alliance Commercial	$4,980.64

VIABAHN ENDOPROSTH VBHR060501A

Facility

$7,918.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,434.08
Max. Negotiated Rate	$7,680.46
Rate for Payer: Cash Price	$4,750.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,542.60
Rate for Payer: Health Management Network Commercial	$6,730.30
Rate for Payer: Kaiser Permanente Commercial	$7,126.20
Rate for Payer: MDX Hawaii PPO	$7,680.46
Rate for Payer: University Health Alliance Commercial	$4,434.08

VIABAHN ENDOPROSTH VBHR060501A

Facility

$7,918.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,454.58
Max. Negotiated Rate	$7,680.46
Rate for Payer: AlohaCare Medicaid	$3,959.00
Rate for Payer: AlohaCare Medicare	$2,454.58
Rate for Payer: Cash Price	$4,750.80
Rate for Payer: Devoted Health Medicare	$2,692.12
Rate for Payer: Hawaii Medical Service Association Medicare	$2,454.58
Rate for Payer: Hawaii Western Management Group Commercial	$5,542.60
Rate for Payer: Health Management Network Commercial	$6,730.30
Rate for Payer: Humana Medicare	$2,454.58
Rate for Payer: Kaiser Permanente Commercial	$7,126.20
Rate for Payer: Kaiser Permanente Medicaid	$4,038.18
Rate for Payer: Kaiser Permanente Medicare	$2,454.58
Rate for Payer: MDX Hawaii PPO	$7,680.46
Rate for Payer: Ohana Health Plan Medicaid	$2,454.58
Rate for Payer: Ohana Health Plan Medicare	$2,454.58
Rate for Payer: UnitedHealthcare Medicare	$2,454.58
Rate for Payer: University Health Alliance Commercial	$4,434.08

VIABAHN GORE VBHR081001A

Facility

$8,002.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,481.12
Max. Negotiated Rate	$7,761.94
Rate for Payer: Cash Price	$4,801.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,601.40
Rate for Payer: Health Management Network Commercial	$6,801.70
Rate for Payer: Kaiser Permanente Commercial	$7,201.80
Rate for Payer: MDX Hawaii PPO	$7,761.94
Rate for Payer: University Health Alliance Commercial	$4,481.12

VIABAHN GORE VBHR081001A

Facility

$8,002.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,480.62
Max. Negotiated Rate	$7,761.94
Rate for Payer: AlohaCare Medicaid	$4,001.00
Rate for Payer: AlohaCare Medicare	$2,480.62
Rate for Payer: Cash Price	$4,801.20
Rate for Payer: Devoted Health Medicare	$2,720.68
Rate for Payer: Hawaii Medical Service Association Medicare	$2,480.62
Rate for Payer: Hawaii Western Management Group Commercial	$5,601.40
Rate for Payer: Health Management Network Commercial	$6,801.70
Rate for Payer: Humana Medicare	$2,480.62
Rate for Payer: Kaiser Permanente Commercial	$7,201.80
Rate for Payer: Kaiser Permanente Medicaid	$4,081.02
Rate for Payer: Kaiser Permanente Medicare	$2,480.62
Rate for Payer: MDX Hawaii PPO	$7,761.94
Rate for Payer: Ohana Health Plan Medicaid	$2,480.62
Rate for Payer: Ohana Health Plan Medicare	$2,480.62
Rate for Payer: UnitedHealthcare Medicare	$2,480.62
Rate for Payer: University Health Alliance Commercial	$4,481.12

VIABAHN SX ENDO VBHR061001A

Facility

$8,684.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,692.04
Max. Negotiated Rate	$8,423.48
Rate for Payer: AlohaCare Medicaid	$4,342.00
Rate for Payer: AlohaCare Medicare	$2,692.04
Rate for Payer: Cash Price	$5,210.40
Rate for Payer: Devoted Health Medicare	$2,952.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2,692.04
Rate for Payer: Hawaii Western Management Group Commercial	$6,078.80
Rate for Payer: Health Management Network Commercial	$7,381.40
Rate for Payer: Humana Medicare	$2,692.04
Rate for Payer: Kaiser Permanente Commercial	$7,815.60
Rate for Payer: Kaiser Permanente Medicaid	$4,428.84
Rate for Payer: Kaiser Permanente Medicare	$2,692.04
Rate for Payer: MDX Hawaii PPO	$8,423.48
Rate for Payer: Ohana Health Plan Medicaid	$2,692.04
Rate for Payer: Ohana Health Plan Medicare	$2,692.04
Rate for Payer: UnitedHealthcare Medicare	$2,692.04
Rate for Payer: University Health Alliance Commercial	$4,863.04

VIABAHN SX ENDO VBHR061001A

Facility

$8,684.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,863.04
Max. Negotiated Rate	$8,423.48
Rate for Payer: Cash Price	$5,210.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,078.80
Rate for Payer: Health Management Network Commercial	$7,381.40
Rate for Payer: Kaiser Permanente Commercial	$7,815.60
Rate for Payer: MDX Hawaii PPO	$8,423.48
Rate for Payer: University Health Alliance Commercial	$4,863.04

VIABAHN VBX EX BAL BXA073901A

Facility

$6,510.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,018.10
Max. Negotiated Rate	$6,314.70
Rate for Payer: AlohaCare Medicaid	$3,255.00
Rate for Payer: AlohaCare Medicare	$2,018.10
Rate for Payer: Cash Price	$3,906.00
Rate for Payer: Devoted Health Medicare	$2,213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,018.10
Rate for Payer: Hawaii Western Management Group Commercial	$4,557.00
Rate for Payer: Health Management Network Commercial	$5,533.50
Rate for Payer: Humana Medicare	$2,018.10
Rate for Payer: Kaiser Permanente Commercial	$5,859.00
Rate for Payer: Kaiser Permanente Medicaid	$3,320.10
Rate for Payer: Kaiser Permanente Medicare	$2,018.10
Rate for Payer: MDX Hawaii PPO	$6,314.70
Rate for Payer: Ohana Health Plan Medicaid	$2,018.10
Rate for Payer: Ohana Health Plan Medicare	$2,018.10
Rate for Payer: UnitedHealthcare Medicare	$2,018.10
Rate for Payer: University Health Alliance Commercial	$3,645.60

VIABAHN VBX EX BAL BXA073901A

Facility

$6,510.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,645.60
Max. Negotiated Rate	$6,314.70
Rate for Payer: Cash Price	$3,906.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,557.00
Rate for Payer: Health Management Network Commercial	$5,533.50
Rate for Payer: Kaiser Permanente Commercial	$5,859.00
Rate for Payer: MDX Hawaii PPO	$6,314.70
Rate for Payer: University Health Alliance Commercial	$3,645.60

VIABAHN VBX EX BAL BXA075902A

Facility

$6,510.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,645.60
Max. Negotiated Rate	$6,314.70
Rate for Payer: Cash Price	$3,906.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,557.00
Rate for Payer: Health Management Network Commercial	$5,533.50
Rate for Payer: Kaiser Permanente Commercial	$5,859.00
Rate for Payer: MDX Hawaii PPO	$6,314.70
Rate for Payer: University Health Alliance Commercial	$3,645.60

VIABAHN VBX EX BAL BXA075902A

Facility

$6,510.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,018.10
Max. Negotiated Rate	$6,314.70
Rate for Payer: AlohaCare Medicaid	$3,255.00
Rate for Payer: AlohaCare Medicare	$2,018.10
Rate for Payer: Cash Price	$3,906.00
Rate for Payer: Devoted Health Medicare	$2,213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,018.10
Rate for Payer: Hawaii Western Management Group Commercial	$4,557.00
Rate for Payer: Health Management Network Commercial	$5,533.50
Rate for Payer: Humana Medicare	$2,018.10
Rate for Payer: Kaiser Permanente Commercial	$5,859.00
Rate for Payer: Kaiser Permanente Medicaid	$3,320.10
Rate for Payer: Kaiser Permanente Medicare	$2,018.10
Rate for Payer: MDX Hawaii PPO	$6,314.70
Rate for Payer: Ohana Health Plan Medicaid	$2,018.10
Rate for Payer: Ohana Health Plan Medicare	$2,018.10
Rate for Payer: UnitedHealthcare Medicare	$2,018.10
Rate for Payer: University Health Alliance Commercial	$3,645.60

VIABAHN VBX EX BAL BXA077901A

Facility

$7,140.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$3,998.40
Max. Negotiated Rate	$6,925.80
Rate for Payer: Cash Price	$4,284.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,998.00
Rate for Payer: Health Management Network Commercial	$6,069.00
Rate for Payer: Kaiser Permanente Commercial	$6,426.00
Rate for Payer: MDX Hawaii PPO	$6,925.80
Rate for Payer: University Health Alliance Commercial	$3,998.40

VIABAHN VBX EX BAL BXA077901A

Facility

$7,140.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,213.40
Max. Negotiated Rate	$6,925.80
Rate for Payer: AlohaCare Medicaid	$3,570.00
Rate for Payer: AlohaCare Medicare	$2,213.40
Rate for Payer: Cash Price	$4,284.00
Rate for Payer: Devoted Health Medicare	$2,427.60
Rate for Payer: Hawaii Medical Service Association Medicare	$2,213.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,998.00
Rate for Payer: Health Management Network Commercial	$6,069.00
Rate for Payer: Humana Medicare	$2,213.40
Rate for Payer: Kaiser Permanente Commercial	$6,426.00
Rate for Payer: Kaiser Permanente Medicaid	$3,641.40
Rate for Payer: Kaiser Permanente Medicare	$2,213.40
Rate for Payer: MDX Hawaii PPO	$6,925.80
Rate for Payer: Ohana Health Plan Medicaid	$2,213.40
Rate for Payer: Ohana Health Plan Medicare	$2,213.40
Rate for Payer: UnitedHealthcare Medicare	$2,213.40
Rate for Payer: University Health Alliance Commercial	$3,998.40

VIABAHN VBX EX BAL BXA097902A

Facility

$7,688.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,305.28
Max. Negotiated Rate	$7,457.36
Rate for Payer: Cash Price	$4,612.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,381.60
Rate for Payer: Health Management Network Commercial	$6,534.80
Rate for Payer: Kaiser Permanente Commercial	$6,919.20
Rate for Payer: MDX Hawaii PPO	$7,457.36
Rate for Payer: University Health Alliance Commercial	$4,305.28

VIABAHN VBX EX BAL BXA097902A

Facility

$7,688.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,383.28
Max. Negotiated Rate	$7,457.36
Rate for Payer: AlohaCare Medicaid	$3,844.00
Rate for Payer: AlohaCare Medicare	$2,383.28
Rate for Payer: Cash Price	$4,612.80
Rate for Payer: Devoted Health Medicare	$2,613.92
Rate for Payer: Hawaii Medical Service Association Medicare	$2,383.28
Rate for Payer: Hawaii Western Management Group Commercial	$5,381.60
Rate for Payer: Health Management Network Commercial	$6,534.80
Rate for Payer: Humana Medicare	$2,383.28
Rate for Payer: Kaiser Permanente Commercial	$6,919.20
Rate for Payer: Kaiser Permanente Medicaid	$3,920.88
Rate for Payer: Kaiser Permanente Medicare	$2,383.28
Rate for Payer: MDX Hawaii PPO	$7,457.36
Rate for Payer: Ohana Health Plan Medicaid	$2,383.28
Rate for Payer: Ohana Health Plan Medicare	$2,383.28
Rate for Payer: UnitedHealthcare Medicare	$2,383.28
Rate for Payer: University Health Alliance Commercial	$4,305.28

VIABAHN VBX EX BAL BXA115901A

Facility

$7,148.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$4,002.88
Max. Negotiated Rate	$6,933.56
Rate for Payer: Cash Price	$4,288.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,003.60
Rate for Payer: Health Management Network Commercial	$6,075.80
Rate for Payer: Kaiser Permanente Commercial	$6,433.20
Rate for Payer: MDX Hawaii PPO	$6,933.56
Rate for Payer: University Health Alliance Commercial	$4,002.88

VIABAHN VBX EX BAL BXA115901A

Facility

$7,148.00

Service Code	HCPCS C1874
Hospital Revenue Code	278
Min. Negotiated Rate	$2,215.88
Max. Negotiated Rate	$6,933.56
Rate for Payer: AlohaCare Medicaid	$3,574.00
Rate for Payer: AlohaCare Medicare	$2,215.88
Rate for Payer: Cash Price	$4,288.80
Rate for Payer: Devoted Health Medicare	$2,430.32
Rate for Payer: Hawaii Medical Service Association Medicare	$2,215.88
Rate for Payer: Hawaii Western Management Group Commercial	$5,003.60
Rate for Payer: Health Management Network Commercial	$6,075.80
Rate for Payer: Humana Medicare	$2,215.88
Rate for Payer: Kaiser Permanente Commercial	$6,433.20
Rate for Payer: Kaiser Permanente Medicaid	$3,645.48
Rate for Payer: Kaiser Permanente Medicare	$2,215.88
Rate for Payer: MDX Hawaii PPO	$6,933.56
Rate for Payer: Ohana Health Plan Medicaid	$2,215.88
Rate for Payer: Ohana Health Plan Medicare	$2,215.88
Rate for Payer: UnitedHealthcare Medicare	$2,215.88
Rate for Payer: University Health Alliance Commercial	$4,002.88

VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]

Facility

$194.00

Service Code	HCPCS J9360
Hospital Revenue Code	250
Min. Negotiated Rate	$164.90
Max. Negotiated Rate	$188.18
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$34.80
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: Kaiser Permanente Commercial	$52.20
Rate for Payer: MDX Hawaii PPO	$56.26
Rate for Payer: MDX Hawaii PPO	$188.18

VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION [8594]

Facility

$194.00

Service Code	HCPCS J9360
Hospital Revenue Code	636
Min. Negotiated Rate	$5.29
Max. Negotiated Rate	$188.18
Rate for Payer: AlohaCare Medicaid	$97.00
Rate for Payer: AlohaCare Medicaid	$29.00
Rate for Payer: AlohaCare Medicare	$17.98
Rate for Payer: AlohaCare Medicare	$60.14
Rate for Payer: Cash Price	$34.80
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$116.40
Rate for Payer: Cash Price	$34.80
Rate for Payer: Devoted Health Medicare	$65.96
Rate for Payer: Devoted Health Medicare	$19.72
Rate for Payer: Hawaii Medical Service Association ABD	$5.29
Rate for Payer: Hawaii Medical Service Association ABD	$5.29
Rate for Payer: Hawaii Medical Service Association Medicare	$17.98
Rate for Payer: Hawaii Medical Service Association Medicare	$60.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.29
Rate for Payer: Hawaii Western Management Group Commercial	$184.30
Rate for Payer: Hawaii Western Management Group Commercial	$55.10
Rate for Payer: Health Management Network Commercial	$49.30
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Humana Medicare	$60.14
Rate for Payer: Humana Medicare	$17.98
Rate for Payer: Kaiser Permanente Commercial	$174.60
Rate for Payer: Kaiser Permanente Commercial	$52.20
Rate for Payer: Kaiser Permanente Medicaid	$29.58
Rate for Payer: Kaiser Permanente Medicaid	$98.94
Rate for Payer: Kaiser Permanente Medicare	$60.14
Rate for Payer: Kaiser Permanente Medicare	$17.98
Rate for Payer: MDX Hawaii PPO	$188.18
Rate for Payer: MDX Hawaii PPO	$56.26
Rate for Payer: Ohana Health Plan Medicaid	$17.98
Rate for Payer: Ohana Health Plan Medicaid	$60.14
Rate for Payer: Ohana Health Plan Medicare	$60.14
Rate for Payer: Ohana Health Plan Medicare	$17.98
Rate for Payer: UnitedHealthcare Medicaid	$34.80
Rate for Payer: UnitedHealthcare Medicaid	$116.40
Rate for Payer: UnitedHealthcare Medicare	$60.14
Rate for Payer: UnitedHealthcare Medicare	$17.98
Rate for Payer: University Health Alliance Commercial	$141.41
Rate for Payer: University Health Alliance Commercial	$42.28

VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]

Facility

$54.00

Service Code	HCPCS J9370
Hospital Revenue Code	636
Min. Negotiated Rate	$7.86
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$16.74
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cash Price	$32.40
Rate for Payer: Devoted Health Medicare	$18.36
Rate for Payer: Hawaii Medical Service Association ABD	$7.86
Rate for Payer: Hawaii Medical Service Association Medicare	$16.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.86
Rate for Payer: Hawaii Western Management Group Commercial	$51.30
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$16.74
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$16.74
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$16.74
Rate for Payer: Ohana Health Plan Medicare	$16.74
Rate for Payer: UnitedHealthcare Medicaid	$32.40
Rate for Payer: UnitedHealthcare Medicare	$16.74
Rate for Payer: University Health Alliance Commercial	$39.36

VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION [8597]

Facility

$54.00

Service Code	HCPCS J9370
Hospital Revenue Code	250
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$32.40
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38

VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [199441]

Facility

$47.00

Service Code	HCPCS J9370
Hospital Revenue Code	250
Min. Negotiated Rate	$39.95
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$28.20
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: MDX Hawaii PPO	$45.59

VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION [199441]

Facility

$47.00

Service Code	HCPCS J9370
Hospital Revenue Code	636
Min. Negotiated Rate	$7.86
Max. Negotiated Rate	$45.59
Rate for Payer: AlohaCare Medicaid	$23.50
Rate for Payer: AlohaCare Medicare	$14.57
Rate for Payer: Cash Price	$28.20
Rate for Payer: Cash Price	$28.20
Rate for Payer: Devoted Health Medicare	$15.98
Rate for Payer: Hawaii Medical Service Association ABD	$7.86
Rate for Payer: Hawaii Medical Service Association Medicare	$14.57
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.86
Rate for Payer: Hawaii Western Management Group Commercial	$44.65
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Humana Medicare	$14.57
Rate for Payer: Kaiser Permanente Commercial	$42.30
Rate for Payer: Kaiser Permanente Medicaid	$23.97
Rate for Payer: Kaiser Permanente Medicare	$14.57
Rate for Payer: MDX Hawaii PPO	$45.59
Rate for Payer: Ohana Health Plan Medicaid	$14.57
Rate for Payer: Ohana Health Plan Medicare	$14.57
Rate for Payer: UnitedHealthcare Medicaid	$28.20
Rate for Payer: UnitedHealthcare Medicare	$14.57
Rate for Payer: University Health Alliance Commercial	$34.26

Know your out-of-pocket cost for care.

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