Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

96366-Infuse Drug Each Addl Hour Greater Than 30 mins

Facility

$350.00

Service Code	HCPCS 96366
Hospital Charge Code	8079982
Hospital Revenue Code	450
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$175.00
Rate for Payer: AlohaCare Medicare	$175.00
Rate for Payer: Cash Price	$227.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Devoted Health Medicare	$192.50
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	$175.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$332.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: Humana Medicare	$175.00
Rate for Payer: Kaiser Permanente Commercial	$315.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$175.00
Rate for Payer: MDX Hawaii PPO	$339.50
Rate for Payer: Ohana Health Plan Medicaid	$175.00
Rate for Payer: Ohana Health Plan Medicare	$175.00
Rate for Payer: UnitedHealthcare Medicare	$175.00
Rate for Payer: University Health Alliance Commercial	$255.12

96366-Infuse Drug Each Addl Hour Greater Than 30 mins

Facility

$350.00

Service Code	HCPCS 96366
Hospital Charge Code	8079982
Hospital Revenue Code	450
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$339.50
Rate for Payer: Cash Price	$227.50
Rate for Payer: Health Management Network Commercial	$297.50
Rate for Payer: Kaiser Permanente Commercial	$315.00
Rate for Payer: MDX Hawaii PPO	$339.50

96366 IV Infusion Ea Addl Hr Charge

Facility

$363.00

Service Code	HCPCS 96366
Hospital Charge Code	8220032
Hospital Revenue Code	940
Min. Negotiated Rate	$308.55
Max. Negotiated Rate	$352.11
Rate for Payer: Cash Price	$235.95
Rate for Payer: Health Management Network Commercial	$308.55
Rate for Payer: Kaiser Permanente Commercial	$326.70
Rate for Payer: MDX Hawaii PPO	$352.11

96366 IV Infusion Ea Addl Hr Charge

Professional

Both

$103.00

Service Code	HCPCS 96366
Hospital Charge Code	8220032
Hospital Revenue Code	521
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$13.35
Rate for Payer: AlohaCare Medicare	$23.30
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$25.63
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$23.85
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$27.96
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$13.35
Rate for Payer: Ohana Health Plan Medicare	$23.30
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97

96366 IV Infusion Ea Addl Hr Charge

Facility

$363.00

Service Code	HCPCS 96366
Hospital Charge Code	8220032
Hospital Revenue Code	940
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$352.11
Rate for Payer: AlohaCare Medicaid	$181.50
Rate for Payer: AlohaCare Medicare	$181.50
Rate for Payer: Cash Price	$235.95
Rate for Payer: Cash Price	$235.95
Rate for Payer: Devoted Health Medicare	$199.65
Rate for Payer: Hawaii Medical Service Association Commercial	$59.80
Rate for Payer: Hawaii Medical Service Association Medicare	$181.50
Rate for Payer: Hawaii Western Management Group Commercial	$344.85
Rate for Payer: Health Management Network Commercial	$308.55
Rate for Payer: Humana Medicare	$181.50
Rate for Payer: Kaiser Permanente Commercial	$326.70
Rate for Payer: Kaiser Permanente Medicaid	$185.13
Rate for Payer: Kaiser Permanente Medicare	$181.50
Rate for Payer: MDX Hawaii PPO	$352.11
Rate for Payer: Ohana Health Plan Medicaid	$181.50
Rate for Payer: Ohana Health Plan Medicare	$181.50
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$181.50
Rate for Payer: University Health Alliance Commercial	$203.28

96367- ED IV tx, sequential infusion

Facility

$379.00

Service Code	HCPCS 96367
Hospital Charge Code	1928301
Hospital Revenue Code	940
Min. Negotiated Rate	$23.03
Max. Negotiated Rate	$367.63
Rate for Payer: AlohaCare Medicaid	$189.50
Rate for Payer: AlohaCare Medicare	$189.50
Rate for Payer: Cash Price	$246.35
Rate for Payer: Cash Price	$246.35
Rate for Payer: Devoted Health Medicare	$208.45
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$189.50
Rate for Payer: Hawaii Western Management Group Commercial	$360.05
Rate for Payer: Health Management Network Commercial	$322.15
Rate for Payer: Humana Medicare	$189.50
Rate for Payer: Kaiser Permanente Commercial	$341.10
Rate for Payer: Kaiser Permanente Medicaid	$193.29
Rate for Payer: Kaiser Permanente Medicare	$189.50
Rate for Payer: MDX Hawaii PPO	$367.63
Rate for Payer: Ohana Health Plan Medicaid	$189.50
Rate for Payer: Ohana Health Plan Medicare	$189.50
Rate for Payer: UnitedHealthcare Medicaid	$23.03
Rate for Payer: UnitedHealthcare Medicare	$189.50
Rate for Payer: University Health Alliance Commercial	$212.24

96367- ED IV tx, sequential infusion

Facility

$379.00

Service Code	HCPCS 96367
Hospital Charge Code	1928301
Hospital Revenue Code	940
Min. Negotiated Rate	$322.15
Max. Negotiated Rate	$367.63
Rate for Payer: Cash Price	$246.35
Rate for Payer: Health Management Network Commercial	$322.15
Rate for Payer: Kaiser Permanente Commercial	$341.10
Rate for Payer: MDX Hawaii PPO	$367.63

96367-Infusion Sequential 1 hr Greater Than 15 mins

Facility

$375.00

Service Code	HCPCS 96367
Hospital Charge Code	8079984
Hospital Revenue Code	450
Min. Negotiated Rate	$318.75
Max. Negotiated Rate	$363.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: MDX Hawaii PPO	$363.75

96367-Infusion Sequential 1 hr Greater Than 15 mins

Facility

$375.00

Service Code	HCPCS 96367
Hospital Charge Code	8079984
Hospital Revenue Code	450
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$187.50
Rate for Payer: AlohaCare Medicare	$187.50
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Devoted Health Medicare	$206.25
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	$187.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$356.25
Rate for Payer: Health Management Network Commercial	$318.75
Rate for Payer: Humana Medicare	$187.50
Rate for Payer: Kaiser Permanente Commercial	$337.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$187.50
Rate for Payer: MDX Hawaii PPO	$363.75
Rate for Payer: Ohana Health Plan Medicaid	$187.50
Rate for Payer: Ohana Health Plan Medicare	$187.50
Rate for Payer: UnitedHealthcare Medicare	$187.50
Rate for Payer: University Health Alliance Commercial	$273.34

96367 IV Inf Addl Seq 16 to 90 Min Charge

Facility

$379.00

Service Code	HCPCS 96367
Hospital Charge Code	8220030
Hospital Revenue Code	940
Min. Negotiated Rate	$23.03
Max. Negotiated Rate	$367.63
Rate for Payer: AlohaCare Medicaid	$189.50
Rate for Payer: AlohaCare Medicare	$189.50
Rate for Payer: Cash Price	$246.35
Rate for Payer: Cash Price	$246.35
Rate for Payer: Devoted Health Medicare	$208.45
Rate for Payer: Hawaii Medical Service Association Commercial	$91.95
Rate for Payer: Hawaii Medical Service Association Medicare	$189.50
Rate for Payer: Hawaii Western Management Group Commercial	$360.05
Rate for Payer: Health Management Network Commercial	$322.15
Rate for Payer: Humana Medicare	$189.50
Rate for Payer: Kaiser Permanente Commercial	$341.10
Rate for Payer: Kaiser Permanente Medicaid	$193.29
Rate for Payer: Kaiser Permanente Medicare	$189.50
Rate for Payer: MDX Hawaii PPO	$367.63
Rate for Payer: Ohana Health Plan Medicaid	$189.50
Rate for Payer: Ohana Health Plan Medicare	$189.50
Rate for Payer: UnitedHealthcare Medicaid	$23.03
Rate for Payer: UnitedHealthcare Medicare	$189.50
Rate for Payer: University Health Alliance Commercial	$212.24

96367 IV Inf Addl Seq 16 to 90 Min Charge

Facility

$379.00

Service Code	HCPCS 96367
Hospital Charge Code	8220030
Hospital Revenue Code	940
Min. Negotiated Rate	$322.15
Max. Negotiated Rate	$367.63
Rate for Payer: Cash Price	$246.35
Rate for Payer: Health Management Network Commercial	$322.15
Rate for Payer: Kaiser Permanente Commercial	$341.10
Rate for Payer: MDX Hawaii PPO	$367.63

96368- ED IV tx, concurrent infusion

Facility

$199.00

Service Code	HCPCS 96368
Hospital Charge Code	1928302
Hospital Revenue Code	450
Min. Negotiated Rate	$99.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
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	$99.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$145.05

96368- ED IV tx, concurrent infusion

Facility

$199.00

Service Code	HCPCS 96368
Hospital Charge Code	1928302
Hospital Revenue Code	450
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

96368-Infusion Concurrent Greater Than 15 mins

Facility

$199.00

Service Code	HCPCS 96368
Hospital Charge Code	8079977
Hospital Revenue Code	450
Min. Negotiated Rate	$99.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
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	$99.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$145.05

96368-Infusion Concurrent Greater Than 15 mins

Facility

$199.00

Service Code	HCPCS 96368
Hospital Charge Code	8079977
Hospital Revenue Code	450
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

96368 IV Infusion Concurrent Charge

Facility

$199.00

Service Code	HCPCS 96368
Hospital Charge Code	8220031
Hospital Revenue Code	940
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$193.03
Rate for Payer: AlohaCare Medicaid	$99.50
Rate for Payer: AlohaCare Medicare	$99.50
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$109.45
Rate for Payer: Hawaii Medical Service Association Medicare	$99.50
Rate for Payer: Hawaii Western Management Group Commercial	$189.05
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Humana Medicare	$99.50
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: Kaiser Permanente Medicaid	$101.49
Rate for Payer: Kaiser Permanente Medicare	$99.50
Rate for Payer: MDX Hawaii PPO	$193.03
Rate for Payer: Ohana Health Plan Medicaid	$99.50
Rate for Payer: Ohana Health Plan Medicare	$99.50
Rate for Payer: UnitedHealthcare Medicaid	$13.30
Rate for Payer: UnitedHealthcare Medicare	$99.50
Rate for Payer: University Health Alliance Commercial	$111.44

96368 IV Infusion Concurrent Charge

Facility

$199.00

Service Code	HCPCS 96368
Hospital Charge Code	8220031
Hospital Revenue Code	940
Min. Negotiated Rate	$169.15
Max. Negotiated Rate	$193.03
Rate for Payer: Cash Price	$129.35
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$179.10
Rate for Payer: MDX Hawaii PPO	$193.03

96372-59 SQ/IM Injection w/ Modification

Facility

$205.00

Service Code	HCPCS 96372 59
Hospital Charge Code	8079988
Hospital Revenue Code	450
Min. Negotiated Rate	$102.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
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	$469.00
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	$450.00
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

96372-59 SQ/IM Injection w/ Modification

Facility

$205.00

Service Code	HCPCS 96372 59
Hospital Charge Code	8079988
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 ED Subq/IM Injection

Facility

$250.00

Service Code	HCPCS 96372
Hospital Charge Code	1928303
Hospital Revenue Code	450
Min. Negotiated Rate	$125.00
Max. Negotiated Rate	$1,600.00
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 ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$125.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
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	$937.50
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 Medicare	$125.00
Rate for Payer: University Health Alliance Commercial	$182.22

96372 ED Subq/IM Injection

Facility

$250.00

Service Code	HCPCS 96372
Hospital Charge Code	1928303
Hospital Revenue Code	450
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50

96372 IM SC Injection Each Charge

Facility

$250.00

Service Code	HCPCS 96372
Hospital Charge Code	8220025
Hospital Revenue Code	940
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50

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	$140.00

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	$105.00
Rate for Payer: AlohaCare Medicare	$105.00
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	$469.00
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	$450.00
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

Know your out-of-pocket cost for care.

All Charges