Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]

Facility

IP

$40.00

Service Code	NDC 65862089610
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]

Facility

IP

$40.00

Service Code	NDC 65862089678
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]

Facility

IP

$40.00

Service Code	NDC 00378698288
Hospital Revenue Code	250
Min. Negotiated Rate	$34.00
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: MDX Hawaii PPO	$38.80

LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]

Facility

OP

$40.00

Service Code	NDC 00378698288
Hospital Revenue Code	637
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: University Health Alliance Commercial	$29.16

LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]

Facility

OP

$40.00

Service Code	NDC 65862089678
Hospital Revenue Code	637
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: University Health Alliance Commercial	$29.16

LANSOPRAZOLE 30 MG DELAYED RELEASE,DISINTEGRATING TABLET [168912]

Facility

OP

$40.00

Service Code	NDC 65862089610
Hospital Revenue Code	637
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$38.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$38.00
Rate for Payer: Health Management Network Commercial	$34.00
Rate for Payer: Kaiser Permanente Commercial	$25.20
Rate for Payer: Kaiser Permanente Medicaid	$20.40
Rate for Payer: MDX Hawaii PPO	$38.80
Rate for Payer: University Health Alliance Commercial	$29.16

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

IP

$29,180.10

Service Code	MSDRG 418
Min. Negotiated Rate	$19,240.68
Max. Negotiated Rate	$29,180.10
Rate for Payer: AlohaCare Medicare	$19,240.68
Rate for Payer: Devoted Health Medicare	$21,164.75
Rate for Payer: Hawaii Medical Service Association Commercial	$27,638.97
Rate for Payer: Hawaii Medical Service Association Medicare	$19,240.68
Rate for Payer: Humana Medicare	$19,240.68
Rate for Payer: Kaiser Permanente Commercial	$29,180.10
Rate for Payer: Kaiser Permanente Medicare	$19,240.68
Rate for Payer: Ohana Health Plan Medicare	$19,240.68
Rate for Payer: UnitedHealthcare Medicare	$19,240.68

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

IP

$41,165.40

Service Code	MSDRG 417
Min. Negotiated Rate	$27,143.51
Max. Negotiated Rate	$41,165.40
Rate for Payer: AlohaCare Medicare	$27,143.51
Rate for Payer: Devoted Health Medicare	$29,857.86
Rate for Payer: Hawaii Medical Service Association Commercial	$30,308.23
Rate for Payer: Hawaii Medical Service Association Medicare	$27,143.51
Rate for Payer: Humana Medicare	$27,143.51
Rate for Payer: Kaiser Permanente Commercial	$41,165.40
Rate for Payer: Kaiser Permanente Medicare	$27,143.51
Rate for Payer: Ohana Health Plan Medicare	$27,143.51
Rate for Payer: UnitedHealthcare Medicare	$27,143.51

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

IP

$23,560.05

Service Code	MSDRG 419
Min. Negotiated Rate	$15,534.96
Max. Negotiated Rate	$23,560.05
Rate for Payer: AlohaCare Medicare	$15,534.96
Rate for Payer: Devoted Health Medicare	$17,088.46
Rate for Payer: Hawaii Medical Service Association Commercial	$17,884.04
Rate for Payer: Hawaii Medical Service Association Medicare	$15,534.96
Rate for Payer: Humana Medicare	$15,534.96
Rate for Payer: Kaiser Permanente Commercial	$23,560.05
Rate for Payer: Kaiser Permanente Medicare	$15,534.96
Rate for Payer: Ohana Health Plan Medicare	$15,534.96
Rate for Payer: UnitedHealthcare Medicare	$15,534.96

LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY

Facility

OP

$13,923.44

Service Code	CPT 59150
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,923.44
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$13,923.44

LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH SALPINGECTOMY AND/OR OOPHORECTOMY

Facility

OP

$14,395.00

Service Code	CPT 59151
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,395.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$11,157.19

LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

Facility

OP

$13,778.00

Service Code	CPT 49320
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$6,743.44

LAPAROSCOPY, SURGICAL, APPENDECTOMY

Facility

OP

$24,500.00

Service Code	CPT 44970
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
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	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$24,500.00

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY

Facility

OP

$20,300.00

Service Code	CPT 47562
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
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	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$20,300.00

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY

Facility

OP

$20,300.00

Service Code	CPT 47563
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
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	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$20,300.00

LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX)

Facility

OP

$13,813.25

Service Code	CPT 57425
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,813.25
Rate for Payer: AlohaCare Medicaid	$12,557.50
Rate for Payer: AlohaCare Medicare	$12,557.50
Rate for Payer: Devoted Health Medicare	$13,813.25
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,557.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$12,557.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$12,557.50
Rate for Payer: Ohana Health Plan Medicaid	$13,813.25
Rate for Payer: Ohana Health Plan Medicare	$12,557.50
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$12,557.50

LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE)

Facility

OP

$13,778.00

Service Code	CPT 44180
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET PROCEDURES)

Facility

OP

$24,500.00

Service Code	CPT 43280
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$12,557.50
Rate for Payer: AlohaCare Medicare	$12,557.50
Rate for Payer: Devoted Health Medicare	$13,813.25
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,557.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$12,557.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$12,557.50
Rate for Payer: Ohana Health Plan Medicaid	$13,813.25
Rate for Payer: Ohana Health Plan Medicare	$12,557.50
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$12,557.50
Rate for Payer: University Health Alliance Commercial	$24,500.00

LAPAROSCOPY, SURGICAL, ESOPHAGOMYOTOMY (HELLER TYPE), WITH FUNDOPLASTY, WHEN PERFORMED

Facility

OP

$14,395.00

Service Code	CPT 43279
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,395.00
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$521.33

LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR FEEDING)

Facility

OP

$8,270.00

Service Code	CPT 44186
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85

LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS

Facility

OP

$24,500.00

Service Code	CPT 58545
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$24,500.00

LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G

Facility

OP

$24,500.00

Service Code	CPT 58546
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$12,557.50
Rate for Payer: AlohaCare Medicare	$12,557.50
Rate for Payer: Devoted Health Medicare	$13,813.25
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,557.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$12,557.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$12,557.50
Rate for Payer: Ohana Health Plan Medicaid	$13,813.25
Rate for Payer: Ohana Health Plan Medicare	$12,557.50
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$12,557.50
Rate for Payer: University Health Alliance Commercial	$24,500.00

LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY

Facility

OP

$24,500.00

Service Code	CPT 50543
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$12,557.50
Rate for Payer: AlohaCare Medicare	$12,557.50
Rate for Payer: Devoted Health Medicare	$13,813.25
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,557.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Humana Medicare	$12,557.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$12,557.50
Rate for Payer: Ohana Health Plan Medicaid	$13,813.25
Rate for Payer: Ohana Health Plan Medicare	$12,557.50
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$12,557.50
Rate for Payer: University Health Alliance Commercial	$24,500.00

LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED;

Facility

OP

$24,500.00

Service Code	CPT 55866
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$12,557.50
Rate for Payer: AlohaCare Medicare	$12,557.50
Rate for Payer: Devoted Health Medicare	$13,813.25
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,557.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$12,557.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$12,557.50
Rate for Payer: Ohana Health Plan Medicaid	$13,813.25
Rate for Payer: Ohana Health Plan Medicare	$12,557.50
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$12,557.50
Rate for Payer: University Health Alliance Commercial	$24,500.00

LAPAROSCOPY, SURGICAL; PYELOPLASTY

Facility

OP

$14,395.00

Service Code	CPT 50544
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,395.00
Rate for Payer: AlohaCare Medicaid	$12,557.50
Rate for Payer: AlohaCare Medicare	$12,557.50
Rate for Payer: Devoted Health Medicare	$13,813.25
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,395.00
Rate for Payer: Hawaii Medical Service Association Medicare	$12,557.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,695.11
Rate for Payer: Humana Medicare	$12,557.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$12,557.50
Rate for Payer: Ohana Health Plan Medicaid	$13,813.25
Rate for Payer: Ohana Health Plan Medicare	$12,557.50
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$12,557.50

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