Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

96360-59 IV Hydration Initial Addl Site w/ Modification

Facility

$664.00

Service Code	HCPCS 96360 59
Hospital Charge Code	8079986
Hospital Revenue Code	450
Min. Negotiated Rate	$332.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$332.00
Rate for Payer: Cash Price	$431.60
Rate for Payer: Cash Price	$431.60
Rate for Payer: Cash Price	$431.60
Rate for Payer: Devoted Health Medicare	$365.20
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$332.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.80
Rate for Payer: Health Management Network Commercial	$564.40
Rate for Payer: Humana Medicare	$332.00
Rate for Payer: Kaiser Permanente Commercial	$597.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$332.00
Rate for Payer: MDX Hawaii PPO	$644.08
Rate for Payer: Ohana Health Plan Medicaid	$332.00
Rate for Payer: Ohana Health Plan Medicare	$332.00
Rate for Payer: UnitedHealthcare Medicare	$332.00
Rate for Payer: University Health Alliance Commercial	$483.99

96360 - ED Hydration, first hour

Facility

$657.00

Service Code	HCPCS 96360
Hospital Charge Code	1928297
Hospital Revenue Code	450
Min. Negotiated Rate	$328.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$328.50
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Devoted Health Medicare	$361.35
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$328.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$624.15
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Humana Medicare	$328.50
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$328.50
Rate for Payer: MDX Hawaii PPO	$637.29
Rate for Payer: Ohana Health Plan Medicaid	$328.50
Rate for Payer: Ohana Health Plan Medicare	$328.50
Rate for Payer: UnitedHealthcare Medicare	$328.50
Rate for Payer: University Health Alliance Commercial	$478.89

96360 - ED Hydration, first hour

Facility

$657.00

Service Code	HCPCS 96360
Hospital Charge Code	1928297
Hospital Revenue Code	450
Min. Negotiated Rate	$558.45
Max. Negotiated Rate	$637.29
Rate for Payer: Cash Price	$427.05
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: MDX Hawaii PPO	$637.29

96360 HYDRATION/IV FLUID INITIAL FIRST HOUR CHARGE

Facility

$657.00

Service Code	HCPCS 96360
Hospital Charge Code	8050442
Hospital Revenue Code	450
Min. Negotiated Rate	$558.45
Max. Negotiated Rate	$637.29
Rate for Payer: Cash Price	$427.05
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: MDX Hawaii PPO	$637.29

96360 HYDRATION/IV FLUID INITIAL FIRST HOUR CHARGE

Facility

$657.00

Service Code	HCPCS 96360
Hospital Charge Code	8050442
Hospital Revenue Code	450
Min. Negotiated Rate	$328.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$328.50
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Devoted Health Medicare	$361.35
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$328.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$624.15
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Humana Medicare	$328.50
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$328.50
Rate for Payer: MDX Hawaii PPO	$637.29
Rate for Payer: Ohana Health Plan Medicaid	$328.50
Rate for Payer: Ohana Health Plan Medicare	$328.50
Rate for Payer: UnitedHealthcare Medicare	$328.50
Rate for Payer: University Health Alliance Commercial	$478.89

96360-IV Hydration Initial 31 min - 1 hr

Facility

$664.00

Service Code	HCPCS 96360
Hospital Charge Code	8079976
Hospital Revenue Code	450
Min. Negotiated Rate	$564.40
Max. Negotiated Rate	$644.08
Rate for Payer: Cash Price	$431.60
Rate for Payer: Health Management Network Commercial	$564.40
Rate for Payer: Kaiser Permanente Commercial	$597.60
Rate for Payer: MDX Hawaii PPO	$644.08

96360-IV Hydration Initial 31 min - 1 hr

Facility

$664.00

Service Code	HCPCS 96360
Hospital Charge Code	8079976
Hospital Revenue Code	450
Min. Negotiated Rate	$332.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$332.00
Rate for Payer: Cash Price	$431.60
Rate for Payer: Cash Price	$431.60
Rate for Payer: Cash Price	$431.60
Rate for Payer: Devoted Health Medicare	$365.20
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$332.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$630.80
Rate for Payer: Health Management Network Commercial	$564.40
Rate for Payer: Humana Medicare	$332.00
Rate for Payer: Kaiser Permanente Commercial	$597.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$332.00
Rate for Payer: MDX Hawaii PPO	$644.08
Rate for Payer: Ohana Health Plan Medicaid	$332.00
Rate for Payer: Ohana Health Plan Medicare	$332.00
Rate for Payer: UnitedHealthcare Medicare	$332.00
Rate for Payer: University Health Alliance Commercial	$483.99

96360 IV Hydration Int 31 to 90 Min Charge

Facility

$657.00

Service Code	HCPCS 96360
Hospital Charge Code	8220029
Hospital Revenue Code	940
Min. Negotiated Rate	$558.45
Max. Negotiated Rate	$637.29
Rate for Payer: Cash Price	$427.05
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: MDX Hawaii PPO	$637.29

96360 IV Hydration Int 31 to 90 Min Charge

Facility

$657.00

Service Code	HCPCS 96360
Hospital Charge Code	8220029
Hospital Revenue Code	940
Min. Negotiated Rate	$38.10
Max. Negotiated Rate	$637.29
Rate for Payer: AlohaCare Medicaid	$328.50
Rate for Payer: AlohaCare Medicare	$328.50
Rate for Payer: Cash Price	$427.05
Rate for Payer: Cash Price	$427.05
Rate for Payer: Devoted Health Medicare	$361.35
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$328.50
Rate for Payer: Hawaii Western Management Group Commercial	$624.15
Rate for Payer: Health Management Network Commercial	$558.45
Rate for Payer: Humana Medicare	$328.50
Rate for Payer: Kaiser Permanente Commercial	$591.30
Rate for Payer: Kaiser Permanente Medicaid	$335.07
Rate for Payer: Kaiser Permanente Medicare	$328.50
Rate for Payer: MDX Hawaii PPO	$637.29
Rate for Payer: Ohana Health Plan Medicaid	$328.50
Rate for Payer: Ohana Health Plan Medicare	$328.50
Rate for Payer: UnitedHealthcare Medicaid	$38.10
Rate for Payer: UnitedHealthcare Medicare	$328.50
Rate for Payer: University Health Alliance Commercial	$478.89

96361- ED Hydration, each additional hour

Facility

$367.00

Service Code	HCPCS 96361
Hospital Charge Code	1928298
Hospital Revenue Code	450
Min. Negotiated Rate	$311.95
Max. Negotiated Rate	$355.99
Rate for Payer: Cash Price	$238.55
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: MDX Hawaii PPO	$355.99

96361- ED Hydration, each additional hour

Facility

$367.00

Service Code	HCPCS 96361
Hospital Charge Code	1928298
Hospital Revenue Code	450
Min. Negotiated Rate	$183.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$183.50
Rate for Payer: Cash Price	$238.55
Rate for Payer: Cash Price	$238.55
Rate for Payer: Cash Price	$238.55
Rate for Payer: Devoted Health Medicare	$201.85
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$183.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$348.65
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Humana Medicare	$183.50
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$183.50
Rate for Payer: MDX Hawaii PPO	$355.99
Rate for Payer: Ohana Health Plan Medicaid	$183.50
Rate for Payer: Ohana Health Plan Medicare	$183.50
Rate for Payer: UnitedHealthcare Medicare	$183.50
Rate for Payer: University Health Alliance Commercial	$267.51

96361-IV Hydration Each Addl Hour Greater Than 30 mins

Facility

$360.00

Service Code	HCPCS 96361
Hospital Charge Code	8079978
Hospital Revenue Code	450
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$349.20
Rate for Payer: Cash Price	$234.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: MDX Hawaii PPO	$349.20

96361-IV Hydration Each Addl Hour Greater Than 30 mins

Facility

$360.00

Service Code	HCPCS 96361
Hospital Charge Code	8079978
Hospital Revenue Code	450
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$180.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Devoted Health Medicare	$198.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$180.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$342.00
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Humana Medicare	$180.00
Rate for Payer: Kaiser Permanente Commercial	$324.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.00
Rate for Payer: MDX Hawaii PPO	$349.20
Rate for Payer: Ohana Health Plan Medicaid	$180.00
Rate for Payer: Ohana Health Plan Medicare	$180.00
Rate for Payer: UnitedHealthcare Medicare	$180.00
Rate for Payer: University Health Alliance Commercial	$262.40

96361 IV Hydration Each Addl Hr Charge

Facility

$367.00

Service Code	HCPCS 96361
Hospital Charge Code	8220028
Hospital Revenue Code	940
Min. Negotiated Rate	$10.81
Max. Negotiated Rate	$355.99
Rate for Payer: AlohaCare Medicaid	$183.50
Rate for Payer: AlohaCare Medicare	$183.50
Rate for Payer: Cash Price	$238.55
Rate for Payer: Cash Price	$238.55
Rate for Payer: Devoted Health Medicare	$201.85
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$183.50
Rate for Payer: Hawaii Western Management Group Commercial	$348.65
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Humana Medicare	$183.50
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: Kaiser Permanente Medicaid	$187.17
Rate for Payer: Kaiser Permanente Medicare	$183.50
Rate for Payer: MDX Hawaii PPO	$355.99
Rate for Payer: Ohana Health Plan Medicaid	$183.50
Rate for Payer: Ohana Health Plan Medicare	$183.50
Rate for Payer: UnitedHealthcare Medicaid	$10.81
Rate for Payer: UnitedHealthcare Medicare	$183.50
Rate for Payer: University Health Alliance Commercial	$267.51

96361 IV Hydration Each Addl Hr Charge

Facility

$367.00

Service Code	HCPCS 96361
Hospital Charge Code	8220028
Hospital Revenue Code	940
Min. Negotiated Rate	$311.95
Max. Negotiated Rate	$355.99
Rate for Payer: Cash Price	$238.55
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: MDX Hawaii PPO	$355.99

96361 - IV INFUSION HYDRATION EACH ADDITIONAL HOUR

Facility

$367.00

Service Code	HCPCS 96361
Hospital Charge Code	8003307
Hospital Revenue Code	450
Min. Negotiated Rate	$311.95
Max. Negotiated Rate	$355.99
Rate for Payer: Cash Price	$238.55
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: MDX Hawaii PPO	$355.99

96361 - IV INFUSION HYDRATION EACH ADDITIONAL HOUR

Facility

$367.00

Service Code	HCPCS 96361
Hospital Charge Code	8003307
Hospital Revenue Code	450
Min. Negotiated Rate	$183.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$183.50
Rate for Payer: Cash Price	$238.55
Rate for Payer: Cash Price	$238.55
Rate for Payer: Cash Price	$238.55
Rate for Payer: Devoted Health Medicare	$201.85
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$183.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$348.65
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Humana Medicare	$183.50
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$183.50
Rate for Payer: MDX Hawaii PPO	$355.99
Rate for Payer: Ohana Health Plan Medicaid	$183.50
Rate for Payer: Ohana Health Plan Medicare	$183.50
Rate for Payer: UnitedHealthcare Medicare	$183.50
Rate for Payer: University Health Alliance Commercial	$267.51

96365-59 Infusion Initial Addl Site w/ Modification

Facility

$800.00

Service Code	HCPCS 96365 59
Hospital Charge Code	8079987
Hospital Revenue Code	450
Min. Negotiated Rate	$400.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$400.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Devoted Health Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$400.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$760.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Humana Medicare	$400.00
Rate for Payer: Kaiser Permanente Commercial	$720.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$400.00
Rate for Payer: MDX Hawaii PPO	$776.00
Rate for Payer: Ohana Health Plan Medicaid	$400.00
Rate for Payer: Ohana Health Plan Medicare	$400.00
Rate for Payer: UnitedHealthcare Medicare	$400.00
Rate for Payer: University Health Alliance Commercial	$583.12

96365-59 Infusion Initial Addl Site w/ Modification

Facility

$800.00

Service Code	HCPCS 96365 59
Hospital Charge Code	8079987
Hospital Revenue Code	450
Min. Negotiated Rate	$680.00
Max. Negotiated Rate	$776.00
Rate for Payer: Cash Price	$520.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Kaiser Permanente Commercial	$720.00
Rate for Payer: MDX Hawaii PPO	$776.00

96365- ED IV tx, first hour

Facility

$770.00

Service Code	HCPCS 96365
Hospital Charge Code	1928299
Hospital Revenue Code	450
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$385.00
Rate for Payer: Cash Price	$500.50
Rate for Payer: Cash Price	$500.50
Rate for Payer: Cash Price	$500.50
Rate for Payer: Devoted Health Medicare	$423.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$385.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$731.50
Rate for Payer: Health Management Network Commercial	$654.50
Rate for Payer: Humana Medicare	$385.00
Rate for Payer: Kaiser Permanente Commercial	$693.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$385.00
Rate for Payer: MDX Hawaii PPO	$746.90
Rate for Payer: Ohana Health Plan Medicaid	$385.00
Rate for Payer: Ohana Health Plan Medicare	$385.00
Rate for Payer: UnitedHealthcare Medicare	$385.00
Rate for Payer: University Health Alliance Commercial	$561.25

96365- ED IV tx, first hour

Facility

$770.00

Service Code	HCPCS 96365
Hospital Charge Code	1928299
Hospital Revenue Code	450
Min. Negotiated Rate	$654.50
Max. Negotiated Rate	$746.90
Rate for Payer: Cash Price	$500.50
Rate for Payer: Health Management Network Commercial	$654.50
Rate for Payer: Kaiser Permanente Commercial	$693.00
Rate for Payer: MDX Hawaii PPO	$746.90

96365-Infusion Drug Initial up to 1 hr Greater Than 15 mins

Facility

$750.00

Service Code	HCPCS 96365
Hospital Charge Code	8079980
Hospital Revenue Code	450
Min. Negotiated Rate	$375.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$375.00
Rate for Payer: Cash Price	$487.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Devoted Health Medicare	$412.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$375.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Humana Medicare	$375.00
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$375.00
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: Ohana Health Plan Medicaid	$375.00
Rate for Payer: Ohana Health Plan Medicare	$375.00
Rate for Payer: UnitedHealthcare Medicare	$375.00
Rate for Payer: University Health Alliance Commercial	$546.67

96365-Infusion Drug Initial up to 1 hr Greater Than 15 mins

Facility

$750.00

Service Code	HCPCS 96365
Hospital Charge Code	8079980
Hospital Revenue Code	450
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$675.00
Rate for Payer: MDX Hawaii PPO	$727.50

96365 IV infusion, for therapy/prophylaxis, or diagnosis; inital, up to one hour

Facility

$305.00

Service Code	HCPCS 96365
Hospital Charge Code	8957886
Hospital Revenue Code	260
Min. Negotiated Rate	$259.25
Max. Negotiated Rate	$295.85
Rate for Payer: Cash Price	$198.25
Rate for Payer: Health Management Network Commercial	$259.25
Rate for Payer: Kaiser Permanente Commercial	$274.50
Rate for Payer: MDX Hawaii PPO	$295.85

96365 IV infusion, for therapy/prophylaxis, or diagnosis; inital, up to one hour

Facility

$305.00

Service Code	HCPCS 96365
Hospital Charge Code	8957886
Hospital Revenue Code	260
Min. Negotiated Rate	$46.51
Max. Negotiated Rate	$295.85
Rate for Payer: AlohaCare Medicaid	$152.50
Rate for Payer: AlohaCare Medicare	$152.50
Rate for Payer: Cash Price	$198.25
Rate for Payer: Cash Price	$198.25
Rate for Payer: Devoted Health Medicare	$167.75
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$152.50
Rate for Payer: Hawaii Western Management Group Commercial	$289.75
Rate for Payer: Health Management Network Commercial	$259.25
Rate for Payer: Humana Medicare	$152.50
Rate for Payer: Kaiser Permanente Commercial	$274.50
Rate for Payer: Kaiser Permanente Medicaid	$155.55
Rate for Payer: Kaiser Permanente Medicare	$152.50
Rate for Payer: MDX Hawaii PPO	$295.85
Rate for Payer: Ohana Health Plan Medicaid	$152.50
Rate for Payer: Ohana Health Plan Medicare	$152.50
Rate for Payer: UnitedHealthcare Medicaid	$46.51
Rate for Payer: UnitedHealthcare Medicare	$152.50
Rate for Payer: University Health Alliance Commercial	$222.31

Know your out-of-pocket cost for care.

All Charges