Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC CLOSED RX MID HUMERUS FX,MANIPULATN

Facility

$6,369.00

Service Code	HCPCS 24505
Hospital Charge Code	7612450501
Hospital Revenue Code	450
Min. Negotiated Rate	$5,413.65
Max. Negotiated Rate	$6,177.93
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: MDX Hawaii PPO	$6,177.93

HC CLOSED RX MID HUMERUS FX,MANIPULATN

Facility

$6,369.00

Service Code	HCPCS 24505
Hospital Charge Code	7612450501
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,177.93
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$6,050.55
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$4,012.47
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,177.93
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,642.36

HC CLOSED RX MONTEGGIA FX/DISLOC ELBOW

Facility

$6,369.00

Service Code	HCPCS 24620
Hospital Charge Code	7612462001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,177.93
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$6,050.55
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$4,012.47
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,177.93
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC CLOSED RX MONTEGGIA FX/DISLOC ELBOW

Facility

$6,369.00

Service Code	HCPCS 24620
Hospital Charge Code	7612462001
Hospital Revenue Code	450
Min. Negotiated Rate	$5,413.65
Max. Negotiated Rate	$6,177.93
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: MDX Hawaii PPO	$6,177.93

HC CLOSED RX MT-PHAL TOE DISLOCATION

Facility

$955.00

Service Code	HCPCS 28630
Hospital Charge Code	4502863001
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$907.25
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$601.65
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$926.35
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$696.10

HC CLOSED RX MT-PHAL TOE DISLOCATION

Facility

$955.00

Service Code	HCPCS 28630
Hospital Charge Code	4502863001
Hospital Revenue Code	450
Min. Negotiated Rate	$811.75
Max. Negotiated Rate	$926.35
Rate for Payer: Cash Price	$573.00
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: MDX Hawaii PPO	$926.35

HC CLOSED RX NOSE FX W STABILIZATN

Facility

$12,637.00

Service Code	HCPCS 21320
Hospital Charge Code	7612132001
Hospital Revenue Code	450
Min. Negotiated Rate	$10,741.45
Max. Negotiated Rate	$12,257.89
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Health Management Network Commercial	$10,741.45
Rate for Payer: MDX Hawaii PPO	$12,257.89

HC CLOSED RX NOSE FX W STABILIZATN

Facility

$12,637.00

Service Code	HCPCS 21320
Hospital Charge Code	7612132001
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$12,257.89
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Cash Price	$7,582.20
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$12,005.15
Rate for Payer: Health Management Network Commercial	$10,741.45
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Commercial	$7,961.31
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: MDX Hawaii PPO	$12,257.89
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC CLOSED RX POST HIP ARTHRPLAS DISLOC

Facility

$955.00

Service Code	HCPCS 27265
Hospital Charge Code	4502726501
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$907.25
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$601.65
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$926.35
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$696.10

HC CLOSED RX POST HIP ARTHRPLAS DISLOC

Facility

$955.00

Service Code	HCPCS 27265
Hospital Charge Code	4502726501
Hospital Revenue Code	450
Min. Negotiated Rate	$811.75
Max. Negotiated Rate	$926.35
Rate for Payer: Cash Price	$573.00
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: MDX Hawaii PPO	$926.35

HC CLOSED RX PROX HUMERUS FX,MANIP

Facility

$6,369.00

Service Code	HCPCS 23605
Hospital Charge Code	7612360501
Hospital Revenue Code	450
Min. Negotiated Rate	$5,413.65
Max. Negotiated Rate	$6,177.93
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: MDX Hawaii PPO	$6,177.93

HC CLOSED RX PROX HUMERUS FX,MANIP

Facility

$6,369.00

Service Code	HCPCS 23605
Hospital Charge Code	7612360501
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,177.93
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$6,050.55
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$4,012.47
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,177.93
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,642.36

HC CLOSED RX PROX/NECK FEMUR FX

Facility

$935.00

Service Code	HCPCS 27230
Hospital Charge Code	7612723001
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Cash Price	$561.00
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$888.25
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$589.05
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$906.95
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$681.52

HC CLOSED RX PROX/NECK FEMUR FX

Facility

$935.00

Service Code	HCPCS 27230
Hospital Charge Code	7612723001
Hospital Revenue Code	450
Min. Negotiated Rate	$794.75
Max. Negotiated Rate	$906.95
Rate for Payer: Cash Price	$561.00
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: MDX Hawaii PPO	$906.95

HC CLOSED RX RADIAL HEAD DISLOC,CHILD

Facility

$955.00

Service Code	HCPCS 24640
Hospital Charge Code	7612464001
Hospital Revenue Code	761
Min. Negotiated Rate	$811.75
Max. Negotiated Rate	$926.35
Rate for Payer: Cash Price	$573.00
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: MDX Hawaii PPO	$926.35

HC CLOSED RX RADIAL HEAD DISLOC,CHILD

Facility

$955.00

Service Code	HCPCS 24640
Hospital Charge Code	7612464001
Hospital Revenue Code	761
Min. Negotiated Rate	$76.75
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$907.25
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$601.65
Rate for Payer: Kaiser Permanente Medicaid	$487.05
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$926.35
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicaid	$76.75
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$696.10

HC CLOSED RX RADIAL HEAD/NECK FX,MANIP

Facility

$6,369.00

Service Code	HCPCS 24655
Hospital Charge Code	4502465501
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,177.93
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$6,050.55
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$4,012.47
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,177.93
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,642.36

HC CLOSED RX RADIAL HEAD/NECK FX,MANIP

Facility

$6,369.00

Service Code	HCPCS 24655
Hospital Charge Code	4502465501
Hospital Revenue Code	450
Min. Negotiated Rate	$5,413.65
Max. Negotiated Rate	$6,177.93
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: MDX Hawaii PPO	$6,177.93

HC CLOSED RX RADIAL SHAFT FX

Facility

$955.00

Service Code	HCPCS 25500
Hospital Charge Code	7612550001
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Cash Price	$573.00
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$907.25
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: Humana Medicare	$291.40
Rate for Payer: Kaiser Permanente Commercial	$601.65
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$926.35
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$696.10

HC CLOSED RX RADIAL SHAFT FX

Facility

$955.00

Service Code	HCPCS 25500
Hospital Charge Code	7612550001
Hospital Revenue Code	450
Min. Negotiated Rate	$811.75
Max. Negotiated Rate	$926.35
Rate for Payer: Cash Price	$573.00
Rate for Payer: Health Management Network Commercial	$811.75
Rate for Payer: MDX Hawaii PPO	$926.35

HC CLOSED RX RADIAL SHAFT FX,MANIPULATN

Facility

$6,369.00

Service Code	HCPCS 25505
Hospital Charge Code	4502550501
Hospital Revenue Code	450
Min. Negotiated Rate	$5,413.65
Max. Negotiated Rate	$6,177.93
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: MDX Hawaii PPO	$6,177.93

HC CLOSED RX RADIAL SHAFT FX,MANIPULATN

Facility

$6,369.00

Service Code	HCPCS 25505
Hospital Charge Code	4502550501
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,177.93
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,050.55
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$4,012.47
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,177.93
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,642.36

HC CLOSED RX RADIAL SHAFT FX W/DISLOCATION

Facility

$6,236.00

Service Code	HCPCS 25520
Hospital Charge Code	7612552001
Hospital Revenue Code	450
Min. Negotiated Rate	$5,300.60
Max. Negotiated Rate	$6,048.92
Rate for Payer: Cash Price	$3,741.60
Rate for Payer: Health Management Network Commercial	$5,300.60
Rate for Payer: MDX Hawaii PPO	$6,048.92

HC CLOSED RX RADIAL SHAFT FX W/DISLOCATION

Facility

$6,236.00

Service Code	HCPCS 25520
Hospital Charge Code	7612552001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,048.92
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,741.60
Rate for Payer: Cash Price	$3,741.60
Rate for Payer: Cash Price	$3,741.60
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$5,924.20
Rate for Payer: Health Management Network Commercial	$5,300.60
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$3,928.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,048.92
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,545.42

HC CLOSED RX RAD/ULNA SHAFT FX,MANIP

Facility

$6,369.00

Service Code	HCPCS 25565
Hospital Charge Code	4502556501
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Cash Price	$3,821.40
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$6,050.55
Rate for Payer: Health Management Network Commercial	$5,413.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$4,012.47
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$6,177.93
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$10,679.55

Know your out-of-pocket cost for care.

All Charges