Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

ES TROCH NAIL, RT, 10MM X 39CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987650
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987644
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987644
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987645
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 10MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987645
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987653
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 30CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987653
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987646
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 33CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987646
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 36CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987654
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 36CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987654
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987656
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 42CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987656
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987651
Hospital Revenue Code	278
Min. Negotiated Rate	$3,404.80
Max. Negotiated Rate	$5,897.60
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 11MM X 45CM X 130

Facility

$6,080.00

Service Code	HCPCS C1713
Hospital Charge Code	12987651
Hospital Revenue Code	278
Min. Negotiated Rate	$3,040.00
Max. Negotiated Rate	$5,897.60
Rate for Payer: AlohaCare Medicaid	$3,040.00
Rate for Payer: AlohaCare Medicare	$3,040.00
Rate for Payer: Cash Price	$3,952.00
Rate for Payer: Devoted Health Medicare	$3,344.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,256.00
Rate for Payer: Health Management Network Commercial	$5,168.00
Rate for Payer: Humana Medicare	$3,040.00
Rate for Payer: Kaiser Permanente Commercial	$5,472.00
Rate for Payer: Kaiser Permanente Medicaid	$3,100.80
Rate for Payer: Kaiser Permanente Medicare	$3,040.00
Rate for Payer: MDX Hawaii PPO	$5,897.60
Rate for Payer: Ohana Health Plan Medicaid	$3,040.00
Rate for Payer: Ohana Health Plan Medicare	$3,040.00
Rate for Payer: UnitedHealthcare Medicare	$3,040.00
Rate for Payer: University Health Alliance Commercial	$3,404.80

ES TROCH NAIL, RT, 12.5MM X 30CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987647
Hospital Revenue Code	278
Min. Negotiated Rate	$3,145.00
Max. Negotiated Rate	$6,101.30
Rate for Payer: AlohaCare Medicaid	$3,145.00
Rate for Payer: AlohaCare Medicare	$3,145.00
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Devoted Health Medicare	$3,459.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3,145.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Humana Medicare	$3,145.00
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: Kaiser Permanente Medicaid	$3,207.90
Rate for Payer: Kaiser Permanente Medicare	$3,145.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: Ohana Health Plan Medicaid	$3,145.00
Rate for Payer: Ohana Health Plan Medicare	$3,145.00
Rate for Payer: UnitedHealthcare Medicare	$3,145.00
Rate for Payer: University Health Alliance Commercial	$3,522.40

ES TROCH NAIL, RT, 12.5MM X 30CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987647
Hospital Revenue Code	278
Min. Negotiated Rate	$3,522.40
Max. Negotiated Rate	$6,101.30
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: University Health Alliance Commercial	$3,522.40

ES TROCH NAIL, RT, 12.5MM X 33CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987657
Hospital Revenue Code	278
Min. Negotiated Rate	$3,522.40
Max. Negotiated Rate	$6,101.30
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: University Health Alliance Commercial	$3,522.40

ES TROCH NAIL, RT, 12.5MM X 33CM X 130

Facility

$6,290.00

Service Code	HCPCS C1713
Hospital Charge Code	12987657
Hospital Revenue Code	278
Min. Negotiated Rate	$3,145.00
Max. Negotiated Rate	$6,101.30
Rate for Payer: AlohaCare Medicaid	$3,145.00
Rate for Payer: AlohaCare Medicare	$3,145.00
Rate for Payer: Cash Price	$4,088.50
Rate for Payer: Devoted Health Medicare	$3,459.50
Rate for Payer: Hawaii Medical Service Association Medicare	$3,145.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,403.00
Rate for Payer: Health Management Network Commercial	$5,346.50
Rate for Payer: Humana Medicare	$3,145.00
Rate for Payer: Kaiser Permanente Commercial	$5,661.00
Rate for Payer: Kaiser Permanente Medicaid	$3,207.90
Rate for Payer: Kaiser Permanente Medicare	$3,145.00
Rate for Payer: MDX Hawaii PPO	$6,101.30
Rate for Payer: Ohana Health Plan Medicaid	$3,145.00
Rate for Payer: Ohana Health Plan Medicare	$3,145.00
Rate for Payer: UnitedHealthcare Medicare	$3,145.00
Rate for Payer: University Health Alliance Commercial	$3,522.40

estrogens-conj 25 mg vial [HHSC]

Facility

$1,165.07

Service Code	HCPCS J1410
Hospital Charge Code	2500208
Hospital Revenue Code	636
Min. Negotiated Rate	$390.74
Max. Negotiated Rate	$1,130.12
Rate for Payer: AlohaCare Medicaid	$582.53
Rate for Payer: AlohaCare Medicare	$582.53
Rate for Payer: Cash Price	$757.30
Rate for Payer: Cash Price	$757.30
Rate for Payer: Devoted Health Medicare	$640.79
Rate for Payer: Hawaii Medical Service Association ABD	$390.74
Rate for Payer: Hawaii Medical Service Association Commercial	$489.65
Rate for Payer: Hawaii Medical Service Association Medicare	$582.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$390.74
Rate for Payer: Hawaii Western Management Group Commercial	$1,106.82
Rate for Payer: Health Management Network Commercial	$990.31
Rate for Payer: Humana Medicare	$582.53
Rate for Payer: Kaiser Permanente Commercial	$1,048.56
Rate for Payer: Kaiser Permanente Medicaid	$594.19
Rate for Payer: Kaiser Permanente Medicare	$582.53
Rate for Payer: MDX Hawaii PPO	$1,130.12
Rate for Payer: Ohana Health Plan Medicaid	$582.53
Rate for Payer: Ohana Health Plan Medicare	$582.53
Rate for Payer: UnitedHealthcare Medicaid	$699.04
Rate for Payer: UnitedHealthcare Medicare	$582.53
Rate for Payer: University Health Alliance Commercial	$849.22

estrogens-conj 25 mg vial [HHSC]

Facility

$1,165.07

Service Code	HCPCS J1410
Hospital Charge Code	2500208
Hospital Revenue Code	250
Min. Negotiated Rate	$990.31
Max. Negotiated Rate	$1,130.12
Rate for Payer: Cash Price	$757.30
Rate for Payer: Health Management Network Commercial	$990.31
Rate for Payer: Kaiser Permanente Commercial	$1,048.56
Rate for Payer: MDX Hawaii PPO	$1,130.12

Estrogens Total Serum FSI

Facility

$112.00

Service Code	HCPCS 82672
Hospital Charge Code	8117907
Hospital Revenue Code	301
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$56.00
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Devoted Health Medicare	$61.60
Rate for Payer: Hawaii Medical Service Association ABD	$29.97
Rate for Payer: Hawaii Medical Service Association Commercial	$27.12
Rate for Payer: Hawaii Medical Service Association Medicare	$56.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.47
Rate for Payer: Hawaii Western Management Group Commercial	$21.70
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$56.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$56.00
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$56.00
Rate for Payer: Ohana Health Plan Medicare	$56.00
Rate for Payer: UnitedHealthcare Medicaid	$29.97
Rate for Payer: UnitedHealthcare Medicare	$56.00
Rate for Payer: University Health Alliance Commercial	$56.05

Estrogens Total Serum FSI

Facility

$112.00

Service Code	HCPCS 82672
Hospital Charge Code	8117907
Hospital Revenue Code	301
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

etanercept 25 mg/0.5 mL PFS [HHSC]

Facility

$2,608.32

Service Code	HCPCS J1438
Hospital Charge Code	2501203
Hospital Revenue Code	636
Min. Negotiated Rate	$411.71
Max. Negotiated Rate	$2,530.07
Rate for Payer: AlohaCare Medicaid	$1,304.16
Rate for Payer: AlohaCare Medicare	$1,304.16
Rate for Payer: Cash Price	$1,695.41
Rate for Payer: Cash Price	$1,695.41
Rate for Payer: Devoted Health Medicare	$1,434.58
Rate for Payer: Hawaii Medical Service Association ABD	$411.71
Rate for Payer: Hawaii Medical Service Association Medicare	$1,304.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$411.71
Rate for Payer: Hawaii Western Management Group Commercial	$2,477.90
Rate for Payer: Health Management Network Commercial	$2,217.07
Rate for Payer: Humana Medicare	$1,304.16
Rate for Payer: Kaiser Permanente Commercial	$2,347.49
Rate for Payer: Kaiser Permanente Medicaid	$1,330.24
Rate for Payer: Kaiser Permanente Medicare	$1,304.16
Rate for Payer: MDX Hawaii PPO	$2,530.07
Rate for Payer: Ohana Health Plan Medicaid	$1,304.16
Rate for Payer: Ohana Health Plan Medicare	$1,304.16
Rate for Payer: UnitedHealthcare Medicaid	$1,564.99
Rate for Payer: UnitedHealthcare Medicare	$1,304.16
Rate for Payer: University Health Alliance Commercial	$1,901.20

etanercept 25 mg/0.5 mL PFS [HHSC]

Facility

$2,608.32

Service Code	HCPCS J1438
Hospital Charge Code	2501203
Hospital Revenue Code	250
Min. Negotiated Rate	$2,217.07
Max. Negotiated Rate	$2,530.07
Rate for Payer: Cash Price	$1,695.41
Rate for Payer: Health Management Network Commercial	$2,217.07
Rate for Payer: Kaiser Permanente Commercial	$2,347.49
Rate for Payer: MDX Hawaii PPO	$2,530.07

Know your out-of-pocket cost for care.

All Charges