Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

96372 IM SC Injection Each Charge

Facility

$250.00

Service Code	HCPCS 96372
Hospital Charge Code	8220025
Hospital Revenue Code	940
Min. Negotiated Rate	$13.87
Max. Negotiated Rate	$242.50
Rate for Payer: AlohaCare Medicaid	$125.00
Rate for Payer: AlohaCare Medicare	$125.00
Rate for Payer: Cash Price	$162.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$137.50
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$125.00
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$125.00
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$125.00
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$125.00
Rate for Payer: Ohana Health Plan Medicare	$125.00
Rate for Payer: UnitedHealthcare Medicaid	$13.87
Rate for Payer: UnitedHealthcare Medicare	$125.00
Rate for Payer: University Health Alliance Commercial	$182.22

96372 IM SC Injection Each TechFee

Facility

$210.00

Service Code	HCPCS 96372
Hospital Charge Code	8343986
Hospital Revenue Code	450
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$105.00
Rate for Payer: Cash Price	$136.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Devoted Health Medicare	$115.50
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	$105.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$199.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Humana Medicare	$105.00
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$105.00
Rate for Payer: MDX Hawaii PPO	$203.70
Rate for Payer: Ohana Health Plan Medicaid	$105.00
Rate for Payer: Ohana Health Plan Medicare	$105.00
Rate for Payer: UnitedHealthcare Medicare	$105.00
Rate for Payer: University Health Alliance Commercial	$153.07

96372 IM SC Injection Each TechFee

Facility

$210.00

Service Code	HCPCS 96372
Hospital Charge Code	8343986
Hospital Revenue Code	450
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$203.70
Rate for Payer: Cash Price	$136.50
Rate for Payer: Health Management Network Commercial	$178.50
Rate for Payer: Kaiser Permanente Commercial	$189.00
Rate for Payer: MDX Hawaii PPO	$203.70

96372 INJECTION IM/SQ-THER, PROPHY, DIAGNOSTIC

Professional

Both

$100.00

Service Code	HCPCS 96372
Hospital Charge Code	8051103
Hospital Revenue Code	975
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicaid	$9.24
Rate for Payer: AlohaCare Medicare	$16.51
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$18.16
Rate for Payer: Hawaii Medical Service Association Medicare	$16.51
Rate for Payer: Hawaii Western Management Group Commercial	$17.25
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$18.16
Rate for Payer: Kaiser Permanente Medicaid	$18.16
Rate for Payer: Kaiser Permanente Medicare	$18.16
Rate for Payer: Ohana Health Plan Medicaid	$9.24
Rate for Payer: Ohana Health Plan Medicare	$16.51
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: UnitedHealthcare Medicare	$16.51

96372-Injection/SQ/IM

Facility

$205.00

Service Code	HCPCS 96372
Hospital Charge Code	8079979
Hospital Revenue Code	450
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

96372-Injection/SQ/IM

Facility

$205.00

Service Code	HCPCS 96372
Hospital Charge Code	8079979
Hospital Revenue Code	450
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
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	$102.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$194.75
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$149.42

96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intermuscular,

Professional

Both

$100.00

Service Code	HCPCS 96372
Hospital Charge Code	9880573
Hospital Revenue Code	975
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicaid	$9.24
Rate for Payer: AlohaCare Medicare	$16.51
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$18.16
Rate for Payer: Hawaii Medical Service Association Medicare	$16.51
Rate for Payer: Hawaii Western Management Group Commercial	$17.25
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$18.16
Rate for Payer: Kaiser Permanente Medicaid	$18.16
Rate for Payer: Kaiser Permanente Medicare	$18.16
Rate for Payer: Ohana Health Plan Medicaid	$9.24
Rate for Payer: Ohana Health Plan Medicare	$16.51
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: UnitedHealthcare Medicare	$16.51

96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular:

Professional

Both

$66.00

Service Code	HCPCS 96372
Hospital Charge Code	8041252
Hospital Revenue Code	975
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$9.24
Rate for Payer: AlohaCare Medicare	$16.51
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$18.16
Rate for Payer: Hawaii Medical Service Association Medicare	$16.51
Rate for Payer: Hawaii Western Management Group Commercial	$17.25
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$18.16
Rate for Payer: Kaiser Permanente Medicaid	$18.16
Rate for Payer: Kaiser Permanente Medicare	$18.16
Rate for Payer: Ohana Health Plan Medicaid	$9.24
Rate for Payer: Ohana Health Plan Medicare	$16.51
Rate for Payer: UnitedHealthcare Medicaid	$9.24
Rate for Payer: UnitedHealthcare Medicare	$16.51

96373 Inj Intra Arterial Charge

Facility

$469.00

Service Code	HCPCS 96373
Hospital Charge Code	8220026
Hospital Revenue Code	940
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

96373 Inj Intra Arterial Charge

Facility

$469.00

Service Code	HCPCS 96373
Hospital Charge Code	8220026
Hospital Revenue Code	940
Min. Negotiated Rate	$11.75
Max. Negotiated Rate	$17,259.00
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,259.00
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,102.18
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$11.75
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$341.85

96373- Intra-Arterial Injection

Facility

$469.00

Service Code	HCPCS 96373
Hospital Charge Code	1928304
Hospital Revenue Code	940
Min. Negotiated Rate	$11.75
Max. Negotiated Rate	$17,259.00
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,259.00
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,102.18
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$11.75
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$341.85

96373- Intra-Arterial Injection

Facility

$469.00

Service Code	HCPCS 96373
Hospital Charge Code	1928304
Hospital Revenue Code	940
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

96374-59 IV Push Initial Drug Addl Site w/ Modification

Facility

$430.00

Service Code	HCPCS 96374 59
Hospital Charge Code	8079989
Hospital Revenue Code	450
Min. Negotiated Rate	$215.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$215.00
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$236.50
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	$215.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Humana Medicare	$215.00
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.00
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: Ohana Health Plan Medicaid	$215.00
Rate for Payer: Ohana Health Plan Medicare	$215.00
Rate for Payer: UnitedHealthcare Medicare	$215.00
Rate for Payer: University Health Alliance Commercial	$313.43

96374-59 IV Push Initial Drug Addl Site w/ Modification

Facility

$430.00

Service Code	HCPCS 96374 59
Hospital Charge Code	8079989
Hospital Revenue Code	450
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$279.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: MDX Hawaii PPO	$417.10

96374- ED Injection, single/initial

Facility

$469.00

Service Code	HCPCS 96374
Hospital Charge Code	1928305
Hospital Revenue Code	940
Min. Negotiated Rate	$36.88
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$36.88
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$341.85

96374- ED Injection, single/initial

Facility

$469.00

Service Code	HCPCS 96374
Hospital Charge Code	1928305
Hospital Revenue Code	940
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

96374 Inj IV Push Initial Drug Charge

Facility

$469.00

Service Code	HCPCS 96374
Hospital Charge Code	8220027
Hospital Revenue Code	940
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$304.85
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

96374 Inj IV Push Initial Drug Charge

Facility

$469.00

Service Code	HCPCS 96374
Hospital Charge Code	8220027
Hospital Revenue Code	940
Min. Negotiated Rate	$36.88
Max. Negotiated Rate	$454.93
Rate for Payer: AlohaCare Medicaid	$234.50
Rate for Payer: AlohaCare Medicare	$234.50
Rate for Payer: Cash Price	$304.85
Rate for Payer: Cash Price	$304.85
Rate for Payer: Devoted Health Medicare	$257.95
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$234.50
Rate for Payer: Hawaii Western Management Group Commercial	$445.55
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Humana Medicare	$234.50
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: Kaiser Permanente Medicaid	$239.19
Rate for Payer: Kaiser Permanente Medicare	$234.50
Rate for Payer: MDX Hawaii PPO	$454.93
Rate for Payer: Ohana Health Plan Medicaid	$234.50
Rate for Payer: Ohana Health Plan Medicare	$234.50
Rate for Payer: UnitedHealthcare Medicaid	$36.88
Rate for Payer: UnitedHealthcare Medicare	$234.50
Rate for Payer: University Health Alliance Commercial	$341.85

96374-IV Push Initial Drug

Facility

$430.00

Service Code	HCPCS 96374
Hospital Charge Code	8079981
Hospital Revenue Code	450
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$279.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: MDX Hawaii PPO	$417.10

96374-IV Push Initial Drug

Facility

$430.00

Service Code	HCPCS 96374
Hospital Charge Code	8079981
Hospital Revenue Code	450
Min. Negotiated Rate	$215.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$215.00
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$236.50
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	$215.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Humana Medicare	$215.00
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.00
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: Ohana Health Plan Medicaid	$215.00
Rate for Payer: Ohana Health Plan Medicare	$215.00
Rate for Payer: UnitedHealthcare Medicare	$215.00
Rate for Payer: University Health Alliance Commercial	$313.43

96375-IV Injection, add new drug

Facility

$335.00

Service Code	HCPCS 96375
Hospital Charge Code	1928306
Hospital Revenue Code	940
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$324.95
Rate for Payer: AlohaCare Medicaid	$167.50
Rate for Payer: AlohaCare Medicare	$167.50
Rate for Payer: Cash Price	$217.75
Rate for Payer: Cash Price	$217.75
Rate for Payer: Devoted Health Medicare	$184.25
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$167.50
Rate for Payer: Hawaii Western Management Group Commercial	$318.25
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Humana Medicare	$167.50
Rate for Payer: Kaiser Permanente Commercial	$301.50
Rate for Payer: Kaiser Permanente Medicaid	$170.85
Rate for Payer: Kaiser Permanente Medicare	$167.50
Rate for Payer: MDX Hawaii PPO	$324.95
Rate for Payer: Ohana Health Plan Medicaid	$167.50
Rate for Payer: Ohana Health Plan Medicare	$167.50
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: UnitedHealthcare Medicare	$167.50
Rate for Payer: University Health Alliance Commercial	$244.18

96375-IV Injection, add new drug

Facility

$335.00

Service Code	HCPCS 96375
Hospital Charge Code	1928306
Hospital Revenue Code	940
Min. Negotiated Rate	$284.75
Max. Negotiated Rate	$324.95
Rate for Payer: Cash Price	$217.75
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Kaiser Permanente Commercial	$301.50
Rate for Payer: MDX Hawaii PPO	$324.95

96375 IV Push Addl Seq New Drug Charge

Facility

$335.00

Service Code	HCPCS 96375
Hospital Charge Code	8220035
Hospital Revenue Code	940
Min. Negotiated Rate	$15.80
Max. Negotiated Rate	$324.95
Rate for Payer: AlohaCare Medicaid	$167.50
Rate for Payer: AlohaCare Medicare	$167.50
Rate for Payer: Cash Price	$217.75
Rate for Payer: Cash Price	$217.75
Rate for Payer: Devoted Health Medicare	$184.25
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$167.50
Rate for Payer: Hawaii Western Management Group Commercial	$318.25
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Humana Medicare	$167.50
Rate for Payer: Kaiser Permanente Commercial	$301.50
Rate for Payer: Kaiser Permanente Medicaid	$170.85
Rate for Payer: Kaiser Permanente Medicare	$167.50
Rate for Payer: MDX Hawaii PPO	$324.95
Rate for Payer: Ohana Health Plan Medicaid	$167.50
Rate for Payer: Ohana Health Plan Medicare	$167.50
Rate for Payer: UnitedHealthcare Medicaid	$15.80
Rate for Payer: UnitedHealthcare Medicare	$167.50
Rate for Payer: University Health Alliance Commercial	$244.18

96375 IV Push Addl Seq New Drug Charge

Facility

$335.00

Service Code	HCPCS 96375
Hospital Charge Code	8220035
Hospital Revenue Code	940
Min. Negotiated Rate	$284.75
Max. Negotiated Rate	$324.95
Rate for Payer: Cash Price	$217.75
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Kaiser Permanente Commercial	$301.50
Rate for Payer: MDX Hawaii PPO	$324.95

96375-IV Push Each Additional New Drug

Facility

$325.00

Service Code	HCPCS 96375
Hospital Charge Code	8079983
Hospital Revenue Code	450
Min. Negotiated Rate	$162.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$162.50
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Devoted Health Medicare	$178.75
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	$162.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$308.75
Rate for Payer: Health Management Network Commercial	$276.25
Rate for Payer: Humana Medicare	$162.50
Rate for Payer: Kaiser Permanente Commercial	$292.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$162.50
Rate for Payer: MDX Hawaii PPO	$315.25
Rate for Payer: Ohana Health Plan Medicaid	$162.50
Rate for Payer: Ohana Health Plan Medicare	$162.50
Rate for Payer: UnitedHealthcare Medicare	$162.50
Rate for Payer: University Health Alliance Commercial	$236.89

Know your out-of-pocket cost for care.

All Charges