Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION

Facility

$1,984.00

Service Code	HCPCS 21400
Hospital Charge Code	4502140001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$637.13
Rate for Payer: AlohaCare Medicare	$637.13
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Devoted Health Medicare	$700.84
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	$637.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,884.80
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Humana Medicare	$637.13
Rate for Payer: Kaiser Permanente Commercial	$1,249.92
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$637.13
Rate for Payer: MDX Hawaii PPO	$1,924.48
Rate for Payer: Ohana Health Plan Medicaid	$700.84
Rate for Payer: Ohana Health Plan Medicare	$637.13
Rate for Payer: UnitedHealthcare Medicare	$637.13
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION

Facility

$1,984.00

Service Code	HCPCS 21400
Hospital Charge Code	4502140001
Hospital Revenue Code	450
Min. Negotiated Rate	$1,686.40
Max. Negotiated Rate	$1,924.48
Rate for Payer: Cash Price	$1,190.40
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: MDX Hawaii PPO	$1,924.48

HC CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; WITH MANIPULATION

Facility

$6,236.00

Service Code	HCPCS 23625
Hospital Charge Code	4502362501
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
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: Cash Price	$3,741.60
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	$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 Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,545.42

HC CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; WITH MANIPULATION

Facility

$6,236.00

Service Code	HCPCS 23625
Hospital Charge Code	4502362501
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 TREATMENT OF GREATER TROCHANTERIC FRACTURE; WITH MANIPULATION

Facility

$935.00

Service Code	HCPCS 27240
Hospital Charge Code	4502724001
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$2,089.55
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$561.00
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	$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	$888.25
Rate for Payer: Health Management Network Commercial	$794.75
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$589.05
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$906.95
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	$681.52

HC CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE; WITH MANIPULATION

Facility

$935.00

Service Code	HCPCS 27240
Hospital Charge Code	4502724001
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 TREATMENT OF HUMERAL SHAFT FRACTURE; WITHOUT MANIPULATION

Facility

$955.00

Service Code	HCPCS 24500
Hospital Charge Code	4502450001
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 TREATMENT OF HUMERAL SHAFT FRACTURE; WITHOUT MANIPULATION

Facility

$955.00

Service Code	HCPCS 24500
Hospital Charge Code	4502450001
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 TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF KNEE, WITH OR WITHOUT MANIPULATION

Facility

$935.00

Service Code	HCPCS 27538
Hospital Charge Code	4502753801
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 TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF KNEE, WITH OR WITHOUT MANIPULATION

Facility

$935.00

Service Code	HCPCS 27538
Hospital Charge Code	4502753801
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 TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE; WITH ANESTHESIA

Facility

$1,057.00

Service Code	HCPCS 28665
Hospital Charge Code	4502866501
Hospital Revenue Code	450
Min. Negotiated Rate	$330.41
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$330.41
Rate for Payer: AlohaCare Medicare	$330.41
Rate for Payer: Cash Price	$634.20
Rate for Payer: Cash Price	$634.20
Rate for Payer: Cash Price	$634.20
Rate for Payer: Devoted Health Medicare	$363.45
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	$330.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,004.15
Rate for Payer: Health Management Network Commercial	$898.45
Rate for Payer: Humana Medicare	$330.41
Rate for Payer: Kaiser Permanente Commercial	$665.91
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$330.41
Rate for Payer: MDX Hawaii PPO	$1,025.29
Rate for Payer: Ohana Health Plan Medicaid	$363.45
Rate for Payer: Ohana Health Plan Medicare	$330.41
Rate for Payer: UnitedHealthcare Medicare	$330.41
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE; WITH ANESTHESIA

Facility

$1,057.00

Service Code	HCPCS 28665
Hospital Charge Code	4502866501
Hospital Revenue Code	450
Min. Negotiated Rate	$898.45
Max. Negotiated Rate	$1,025.29
Rate for Payer: Cash Price	$634.20
Rate for Payer: Health Management Network Commercial	$898.45
Rate for Payer: MDX Hawaii PPO	$1,025.29

HC CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE; WITHOUT ANESTHESIA

Facility

$6,369.00

Service Code	HCPCS 28635
Hospital Charge Code	4502863501
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 TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE; WITHOUT ANESTHESIA

Facility

$6,369.00

Service Code	HCPCS 28635
Hospital Charge Code	4502863501
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 TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITHOUT MANIPULATION

Facility

$6,236.00

Service Code	HCPCS 27238
Hospital Charge Code	4502723801
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 TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITHOUT MANIPULATION

Facility

$6,236.00

Service Code	HCPCS 27238
Hospital Charge Code	4502723801
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
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: Cash Price	$3,741.60
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	$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 TREATMENT OF LUNATE DISLOCATION; WITH MANIPULATION

Facility

$6,236.00

Service Code	HCPCS 25690
Hospital Charge Code	4502569001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,048.92
Rate for Payer: MDX Hawaii PPO	$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: 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	$4,545.42

HC CLOSED TREATMENT OF LUNATE DISLOCATION; WITH MANIPULATION

Facility

$6,236.00

Service Code	HCPCS 25690
Hospital Charge Code	4502569001
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 TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE; WITHOUT MANIPULATION

Facility

$2,027.00

Service Code	HCPCS 21450
Hospital Charge Code	4502145001
Hospital Revenue Code	450
Min. Negotiated Rate	$1,722.95
Max. Negotiated Rate	$1,966.19
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Health Management Network Commercial	$1,722.95
Rate for Payer: MDX Hawaii PPO	$1,966.19

HC CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE; WITHOUT MANIPULATION

Facility

$2,027.00

Service Code	HCPCS 21450
Hospital Charge Code	4502145001
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,536.00
Rate for Payer: AlohaCare Medicaid	$637.13
Rate for Payer: AlohaCare Medicare	$637.13
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Devoted Health Medicare	$700.84
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	$637.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$496.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,925.65
Rate for Payer: Health Management Network Commercial	$1,722.95
Rate for Payer: Humana Medicare	$637.13
Rate for Payer: Kaiser Permanente Commercial	$1,277.01
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$637.13
Rate for Payer: MDX Hawaii PPO	$1,966.19
Rate for Payer: Ohana Health Plan Medicaid	$700.84
Rate for Payer: Ohana Health Plan Medicare	$637.13
Rate for Payer: UnitedHealthcare Medicare	$637.13
Rate for Payer: University Health Alliance Commercial	$1,477.48

HC CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION

Facility

$955.00

Service Code	HCPCS 28475
Hospital Charge Code	4502847501
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 TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION

Facility

$955.00

Service Code	HCPCS 28475
Hospital Charge Code	4502847501
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 TREATMENT OF METATARSOPHALANGEAL DISLOCATION; WITH MANIPULATION

Facility

$935.00

Service Code	HCPCS 28540
Hospital Charge Code	4502854001
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 TREATMENT OF METATARSOPHALANGEAL DISLOCATION; WITH MANIPULATION

Facility

$935.00

Service Code	HCPCS 28540
Hospital Charge Code	4502854001
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	$561.00
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	$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	$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 TREATMENT OF METATARSOPHALANGEAL DISLOCATION; WITHOUT MANIPULATION

Facility

$935.00

Service Code	HCPCS 28530
Hospital Charge Code	4502853001
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

Know your out-of-pocket cost for care.

All Charges