Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG INJ IM/SUBQ

Facility

$261.00

Service Code	HCPCS 96372
Hospital Charge Code	H9400110
Hospital Revenue Code	940
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

HCHG INJ IM/SUBQ

Facility

$261.00

Service Code	HCPCS 96372
Hospital Charge Code	H9400110
Hospital Revenue Code	940
Min. Negotiated Rate	$13.87
Max. Negotiated Rate	$258.39
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$234.90
Rate for Payer: Cash Price	$169.65
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$258.39
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$234.90
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$234.90
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$234.90
Rate for Payer: Ohana Health Plan Medicare	$234.90
Rate for Payer: UnitedHealthcare Medicaid	$13.87
Rate for Payer: UnitedHealthcare Medicare	$234.90
Rate for Payer: University Health Alliance Commercial	$190.24

HCHG INJ NERVE BLOCK OTHER PERIPH

Facility

$3,543.00

Service Code	HCPCS 64450
Hospital Charge Code	H4500514
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,771.50
Rate for Payer: AlohaCare Medicare	$3,188.70
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Devoted Health Medicare	$3,507.57
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,188.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$3,188.70
Rate for Payer: Kaiser Permanente Commercial	$3,188.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,188.70
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$3,188.70
Rate for Payer: Ohana Health Plan Medicare	$3,188.70
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,188.70
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ NERVE BLOCK OTHER PERIPH

Facility

$3,543.00

Service Code	HCPCS 64450
Hospital Charge Code	H4500514
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Kaiser Permanente Commercial	$3,188.70
Rate for Payer: MDX Hawaii PPO	$3,436.71

HCHG INJ SNGL/MULT TRIGGER PTS 1-2 MUSC

Facility

$1,721.00

Service Code	HCPCS 20552
Hospital Charge Code	H4500520
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Kaiser Permanente Commercial	$1,548.90
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ SNGL/MULT TRIGGER PTS 1-2 MUSC

Facility

$1,721.00

Service Code	HCPCS 20552
Hospital Charge Code	H4500520
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$860.50
Rate for Payer: AlohaCare Medicare	$1,548.90
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$1,703.79
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,548.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$1,548.90
Rate for Payer: Kaiser Permanente Commercial	$1,548.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,548.90
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$1,548.90
Rate for Payer: Ohana Health Plan Medicare	$1,548.90
Rate for Payer: UnitedHealthcare Medicare	$1,548.90
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ THERAPEUTIC SUBQ/IM

Facility

$261.00

Service Code	HCPCS 96372
Hospital Charge Code	H4500518
Hospital Revenue Code	450
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$234.90
Rate for Payer: Cash Price	$169.65
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$258.39
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$234.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$234.90
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$234.90
Rate for Payer: Ohana Health Plan Medicare	$234.90
Rate for Payer: UnitedHealthcare Medicare	$234.90
Rate for Payer: University Health Alliance Commercial	$190.24

HCHG INJ THERAPEUTIC SUBQ/IM

Facility

$261.00

Service Code	HCPCS 96372
Hospital Charge Code	H4500518
Hospital Revenue Code	450
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

HCHG INSERT CATH PLEURA W/ IMAGE

Facility

$4,880.00

Service Code	HCPCS 32557
Hospital Charge Code	H4501062
Hospital Revenue Code	450
Min. Negotiated Rate	$4,148.00
Max. Negotiated Rate	$4,733.60
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Health Management Network Commercial	$4,148.00
Rate for Payer: Kaiser Permanente Commercial	$4,392.00
Rate for Payer: MDX Hawaii PPO	$4,733.60

HCHG INSERT CATH PLEURA W/ IMAGE

Facility

$4,880.00

Service Code	HCPCS 32557
Hospital Charge Code	H4501062
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,831.20
Rate for Payer: AlohaCare Medicaid	$2,440.00
Rate for Payer: AlohaCare Medicare	$4,392.00
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Devoted Health Medicare	$4,831.20
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,392.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,636.00
Rate for Payer: Health Management Network Commercial	$4,148.00
Rate for Payer: Humana Medicare	$4,392.00
Rate for Payer: Kaiser Permanente Commercial	$4,392.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,392.00
Rate for Payer: MDX Hawaii PPO	$4,733.60
Rate for Payer: Ohana Health Plan Medicaid	$4,392.00
Rate for Payer: Ohana Health Plan Medicare	$4,392.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$4,392.00
Rate for Payer: University Health Alliance Commercial	$3,557.03

HCHG INSERT CATH PLEURA W/O IMAGE

Facility

$4,865.00

Service Code	HCPCS 32556
Hospital Charge Code	H4501061
Hospital Revenue Code	450
Min. Negotiated Rate	$4,135.25
Max. Negotiated Rate	$4,719.05
Rate for Payer: Cash Price	$3,162.25
Rate for Payer: Health Management Network Commercial	$4,135.25
Rate for Payer: Kaiser Permanente Commercial	$4,378.50
Rate for Payer: MDX Hawaii PPO	$4,719.05

HCHG INSERT CATH PLEURA W/O IMAGE

Facility

$4,865.00

Service Code	HCPCS 32556
Hospital Charge Code	H4501061
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,816.35
Rate for Payer: AlohaCare Medicaid	$2,432.50
Rate for Payer: AlohaCare Medicare	$4,378.50
Rate for Payer: Cash Price	$3,162.25
Rate for Payer: Cash Price	$3,162.25
Rate for Payer: Devoted Health Medicare	$4,816.35
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,378.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,621.75
Rate for Payer: Health Management Network Commercial	$4,135.25
Rate for Payer: Humana Medicare	$4,378.50
Rate for Payer: Kaiser Permanente Commercial	$4,378.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,378.50
Rate for Payer: MDX Hawaii PPO	$4,719.05
Rate for Payer: Ohana Health Plan Medicaid	$4,378.50
Rate for Payer: Ohana Health Plan Medicare	$4,378.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,378.50
Rate for Payer: University Health Alliance Commercial	$3,546.10

HCHG INSERT INDWELL BLAD CATH COMP

Facility

$993.00

Service Code	HCPCS 51703
Hospital Charge Code	H4500522
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$496.50
Rate for Payer: AlohaCare Medicare	$893.70
Rate for Payer: Cash Price	$645.45
Rate for Payer: Cash Price	$645.45
Rate for Payer: Devoted Health Medicare	$983.07
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$893.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$943.35
Rate for Payer: Health Management Network Commercial	$844.05
Rate for Payer: Humana Medicare	$893.70
Rate for Payer: Kaiser Permanente Commercial	$893.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$893.70
Rate for Payer: MDX Hawaii PPO	$963.21
Rate for Payer: Ohana Health Plan Medicaid	$893.70
Rate for Payer: Ohana Health Plan Medicare	$893.70
Rate for Payer: UnitedHealthcare Medicare	$893.70
Rate for Payer: University Health Alliance Commercial	$723.80

HCHG INSERT INDWELL BLAD CATH COMP

Facility

$993.00

Service Code	HCPCS 51703
Hospital Charge Code	H4500522
Hospital Revenue Code	450
Min. Negotiated Rate	$844.05
Max. Negotiated Rate	$963.21
Rate for Payer: Cash Price	$645.45
Rate for Payer: Health Management Network Commercial	$844.05
Rate for Payer: Kaiser Permanente Commercial	$893.70
Rate for Payer: MDX Hawaii PPO	$963.21

HCHG INSERT INDWELL BLAD CATH SIMP

Facility

$475.00

Service Code	HCPCS 51702
Hospital Charge Code	H4500524
Hospital Revenue Code	450
Min. Negotiated Rate	$403.75
Max. Negotiated Rate	$460.75
Rate for Payer: Cash Price	$308.75
Rate for Payer: Health Management Network Commercial	$403.75
Rate for Payer: Kaiser Permanente Commercial	$427.50
Rate for Payer: MDX Hawaii PPO	$460.75

HCHG INSERT INDWELL BLAD CATH SIMP

Facility

$475.00

Service Code	HCPCS 51702
Hospital Charge Code	H4500524
Hospital Revenue Code	450
Min. Negotiated Rate	$237.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.50
Rate for Payer: AlohaCare Medicare	$427.50
Rate for Payer: Cash Price	$308.75
Rate for Payer: Cash Price	$308.75
Rate for Payer: Devoted Health Medicare	$470.25
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$451.25
Rate for Payer: Health Management Network Commercial	$403.75
Rate for Payer: Humana Medicare	$427.50
Rate for Payer: Kaiser Permanente Commercial	$427.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.50
Rate for Payer: MDX Hawaii PPO	$460.75
Rate for Payer: Ohana Health Plan Medicaid	$427.50
Rate for Payer: Ohana Health Plan Medicare	$427.50
Rate for Payer: UnitedHealthcare Medicare	$427.50
Rate for Payer: University Health Alliance Commercial	$346.23

HCHG INSERT IUD

Facility

$188.00

Service Code	HCPCS 58300
Hospital Charge Code	H4501157
Hospital Revenue Code	450
Min. Negotiated Rate	$94.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$94.00
Rate for Payer: AlohaCare Medicare	$169.20
Rate for Payer: Cash Price	$122.20
Rate for Payer: Cash Price	$122.20
Rate for Payer: Devoted Health Medicare	$186.12
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$169.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$178.60
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Humana Medicare	$169.20
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$169.20
Rate for Payer: MDX Hawaii PPO	$182.36
Rate for Payer: Ohana Health Plan Medicaid	$169.20
Rate for Payer: Ohana Health Plan Medicare	$169.20
Rate for Payer: UnitedHealthcare Medicare	$169.20
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INSERT IUD

Facility

$188.00

Service Code	HCPCS 58300
Hospital Charge Code	H4501157
Hospital Revenue Code	450
Min. Negotiated Rate	$159.80
Max. Negotiated Rate	$182.36
Rate for Payer: Cash Price	$122.20
Rate for Payer: Health Management Network Commercial	$159.80
Rate for Payer: Kaiser Permanente Commercial	$169.20
Rate for Payer: MDX Hawaii PPO	$182.36

HCHG INSERT NON INDWELL BLAD CATH

Facility

$458.00

Service Code	HCPCS 51701
Hospital Charge Code	H4500526
Hospital Revenue Code	450
Min. Negotiated Rate	$389.30
Max. Negotiated Rate	$444.26
Rate for Payer: Cash Price	$297.70
Rate for Payer: Health Management Network Commercial	$389.30
Rate for Payer: Kaiser Permanente Commercial	$412.20
Rate for Payer: MDX Hawaii PPO	$444.26

HCHG INSERT NON INDWELL BLAD CATH

Facility

$458.00

Service Code	HCPCS 51701
Hospital Charge Code	H4500526
Hospital Revenue Code	450
Min. Negotiated Rate	$229.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$229.00
Rate for Payer: AlohaCare Medicare	$412.20
Rate for Payer: Cash Price	$297.70
Rate for Payer: Cash Price	$297.70
Rate for Payer: Devoted Health Medicare	$453.42
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$412.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$435.10
Rate for Payer: Health Management Network Commercial	$389.30
Rate for Payer: Humana Medicare	$412.20
Rate for Payer: Kaiser Permanente Commercial	$412.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$412.20
Rate for Payer: MDX Hawaii PPO	$444.26
Rate for Payer: Ohana Health Plan Medicaid	$412.20
Rate for Payer: Ohana Health Plan Medicare	$412.20
Rate for Payer: UnitedHealthcare Medicare	$412.20
Rate for Payer: University Health Alliance Commercial	$333.84

HCHG INSERT NON-TUNNL CVP<5YO

Facility

$8,375.00

Service Code	HCPCS 36555
Hospital Charge Code	H4500528
Hospital Revenue Code	450
Min. Negotiated Rate	$7,118.75
Max. Negotiated Rate	$8,123.75
Rate for Payer: Cash Price	$5,443.75
Rate for Payer: Health Management Network Commercial	$7,118.75
Rate for Payer: Kaiser Permanente Commercial	$7,537.50
Rate for Payer: MDX Hawaii PPO	$8,123.75

HCHG INSERT NON-TUNNL CVP<5YO

Facility

$8,375.00

Service Code	HCPCS 36555
Hospital Charge Code	H4500528
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$8,291.25
Rate for Payer: AlohaCare Medicaid	$4,187.50
Rate for Payer: AlohaCare Medicare	$7,537.50
Rate for Payer: Cash Price	$5,443.75
Rate for Payer: Cash Price	$5,443.75
Rate for Payer: Devoted Health Medicare	$8,291.25
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,537.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,956.25
Rate for Payer: Health Management Network Commercial	$7,118.75
Rate for Payer: Humana Medicare	$7,537.50
Rate for Payer: Kaiser Permanente Commercial	$7,537.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$7,537.50
Rate for Payer: MDX Hawaii PPO	$8,123.75
Rate for Payer: Ohana Health Plan Medicaid	$7,537.50
Rate for Payer: Ohana Health Plan Medicare	$7,537.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$7,537.50
Rate for Payer: University Health Alliance Commercial	$6,104.54

HCHG INSERT NON-TUNNL CVP>5YO

Facility

$8,375.00

Service Code	HCPCS 36556
Hospital Charge Code	H4500530
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$8,291.25
Rate for Payer: AlohaCare Medicaid	$4,187.50
Rate for Payer: AlohaCare Medicare	$7,537.50
Rate for Payer: Cash Price	$5,443.75
Rate for Payer: Cash Price	$5,443.75
Rate for Payer: Devoted Health Medicare	$8,291.25
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,537.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,956.25
Rate for Payer: Health Management Network Commercial	$7,118.75
Rate for Payer: Humana Medicare	$7,537.50
Rate for Payer: Kaiser Permanente Commercial	$7,537.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$7,537.50
Rate for Payer: MDX Hawaii PPO	$8,123.75
Rate for Payer: Ohana Health Plan Medicaid	$7,537.50
Rate for Payer: Ohana Health Plan Medicare	$7,537.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$7,537.50
Rate for Payer: University Health Alliance Commercial	$6,104.54

HCHG INSERT NON-TUNNL CVP>5YO

Facility

$8,375.00

Service Code	HCPCS 36556
Hospital Charge Code	H4500530
Hospital Revenue Code	450
Min. Negotiated Rate	$7,118.75
Max. Negotiated Rate	$8,123.75
Rate for Payer: Cash Price	$5,443.75
Rate for Payer: Health Management Network Commercial	$7,118.75
Rate for Payer: Kaiser Permanente Commercial	$7,537.50
Rate for Payer: MDX Hawaii PPO	$8,123.75

HCHG INSERT PICC WO PORT/PUMP 5YR>

Facility

$3,598.00

Service Code	HCPCS 36569
Hospital Charge Code	H4500532
Hospital Revenue Code	450
Min. Negotiated Rate	$3,058.30
Max. Negotiated Rate	$3,490.06
Rate for Payer: Cash Price	$2,338.70
Rate for Payer: Health Management Network Commercial	$3,058.30
Rate for Payer: Kaiser Permanente Commercial	$3,238.20
Rate for Payer: MDX Hawaii PPO	$3,490.06

Know your out-of-pocket cost for care.

All Charges