Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC

Facility

$18,511.26

Service Code	MSDRG 847
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC

Facility

$18,511.26

Service Code	MSDRG 846
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC

Facility

$18,511.26

Service Code	MSDRG 848
Min. Negotiated Rate	$18,511.26
Max. Negotiated Rate	$18,511.26
Rate for Payer: Hawaii Medical Service Association Commercial	$18,511.26

CHEST PAIN

Facility

$11,448.07

Service Code	MSDRG 313
Min. Negotiated Rate	$11,448.07
Max. Negotiated Rate	$11,448.07
Rate for Payer: Hawaii Medical Service Association Commercial	$11,448.07

CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

Professional

Both

$222.00

Service Code	HCPCS 76377
Min. Negotiated Rate	$50.53
Max. Negotiated Rate	$188.71
Rate for Payer: AlohaCare Medicaid	$50.53
Rate for Payer: AlohaCare Medicare	$84.80
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cash Price	$133.20
Rate for Payer: Devoted Health Medicare	$93.28
Rate for Payer: Hawaii Medical Service Association Medicare	$84.80
Rate for Payer: Hawaii Western Management Group Commercial	$188.71
Rate for Payer: Health Management Network Commercial	$188.70
Rate for Payer: Kaiser Permanente Commercial	$101.76
Rate for Payer: Kaiser Permanente Medicaid	$101.76
Rate for Payer: Kaiser Permanente Medicare	$101.76
Rate for Payer: Ohana Health Plan Medicaid	$50.53
Rate for Payer: Ohana Health Plan Medicare	$84.80
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$84.80

CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

Professional

Both

$156.00

Service Code	HCPCS 76377 TC
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$188.71
Rate for Payer: AlohaCare Medicaid	$50.53
Rate for Payer: AlohaCare Medicare	$47.10
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$51.81
Rate for Payer: Hawaii Medical Service Association Medicare	$47.10
Rate for Payer: Hawaii Western Management Group Commercial	$188.71
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$56.52
Rate for Payer: Kaiser Permanente Medicaid	$56.52
Rate for Payer: Kaiser Permanente Medicare	$56.52
Rate for Payer: Ohana Health Plan Medicaid	$50.53
Rate for Payer: Ohana Health Plan Medicare	$47.10
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$47.10

CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION

Professional

Both

$66.00

Service Code	HCPCS 76377 26
Min. Negotiated Rate	$37.70
Max. Negotiated Rate	$188.71
Rate for Payer: AlohaCare Medicaid	$50.53
Rate for Payer: AlohaCare Medicare	$37.70
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cash Price	$39.60
Rate for Payer: Devoted Health Medicare	$41.47
Rate for Payer: Hawaii Medical Service Association Medicare	$37.70
Rate for Payer: Hawaii Western Management Group Commercial	$188.71
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$45.24
Rate for Payer: Kaiser Permanente Medicaid	$45.24
Rate for Payer: Kaiser Permanente Medicare	$45.24
Rate for Payer: Ohana Health Plan Medicaid	$50.53
Rate for Payer: Ohana Health Plan Medicare	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$50.53
Rate for Payer: UnitedHealthcare Medicare	$37.70

CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION

Professional

Both

$77.00

Service Code	HCPCS 76376
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$150.85
Rate for Payer: AlohaCare Medicaid	$16.38
Rate for Payer: AlohaCare Medicare	$27.57
Rate for Payer: Cash Price	$46.20
Rate for Payer: Cash Price	$46.20
Rate for Payer: Devoted Health Medicare	$30.33
Rate for Payer: Hawaii Medical Service Association Medicare	$27.57
Rate for Payer: Hawaii Western Management Group Commercial	$150.85
Rate for Payer: Health Management Network Commercial	$65.45
Rate for Payer: Kaiser Permanente Commercial	$33.08
Rate for Payer: Kaiser Permanente Medicaid	$33.08
Rate for Payer: Kaiser Permanente Medicare	$33.08
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$27.57
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: UnitedHealthcare Medicare	$27.57

CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION

Professional

Both

$17.00

Service Code	HCPCS 76376 26
Min. Negotiated Rate	$9.53
Max. Negotiated Rate	$150.85
Rate for Payer: AlohaCare Medicaid	$16.38
Rate for Payer: AlohaCare Medicare	$9.53
Rate for Payer: Cash Price	$10.20
Rate for Payer: Cash Price	$10.20
Rate for Payer: Devoted Health Medicare	$10.48
Rate for Payer: Hawaii Medical Service Association Medicare	$9.53
Rate for Payer: Hawaii Western Management Group Commercial	$150.85
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$11.44
Rate for Payer: Kaiser Permanente Medicaid	$11.44
Rate for Payer: Kaiser Permanente Medicare	$11.44
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$9.53
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: UnitedHealthcare Medicare	$9.53

CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION

Professional

Both

$60.00

Service Code	HCPCS 76376 TC
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$150.85
Rate for Payer: AlohaCare Medicaid	$16.38
Rate for Payer: AlohaCare Medicare	$18.04
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Devoted Health Medicare	$19.84
Rate for Payer: Hawaii Medical Service Association Medicare	$18.04
Rate for Payer: Hawaii Western Management Group Commercial	$150.85
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Commercial	$21.65
Rate for Payer: Kaiser Permanente Medicaid	$21.65
Rate for Payer: Kaiser Permanente Medicare	$21.65
Rate for Payer: Ohana Health Plan Medicaid	$16.38
Rate for Payer: Ohana Health Plan Medicare	$18.04
Rate for Payer: UnitedHealthcare Medicaid	$16.38
Rate for Payer: UnitedHealthcare Medicare	$18.04

CHG ANGIOGRAPHY EXTREMITY BILATERAL RS&I

Professional

Both

$421.00

Service Code	HCPCS 75716
Min. Negotiated Rate	$103.42
Max. Negotiated Rate	$626.28
Rate for Payer: AlohaCare Medicaid	$103.42
Rate for Payer: AlohaCare Medicare	$171.87
Rate for Payer: Cash Price	$252.60
Rate for Payer: Cash Price	$252.60
Rate for Payer: Devoted Health Medicare	$189.06
Rate for Payer: Hawaii Medical Service Association Medicare	$171.87
Rate for Payer: Hawaii Western Management Group Commercial	$626.28
Rate for Payer: Health Management Network Commercial	$357.85
Rate for Payer: Kaiser Permanente Commercial	$206.24
Rate for Payer: Kaiser Permanente Medicaid	$206.24
Rate for Payer: Kaiser Permanente Medicare	$206.24
Rate for Payer: Ohana Health Plan Medicaid	$103.42
Rate for Payer: Ohana Health Plan Medicare	$171.87
Rate for Payer: UnitedHealthcare Medicaid	$103.42
Rate for Payer: UnitedHealthcare Medicare	$171.87

CHG ANGIOGRAPHY EXTREMITY BILATERAL RS&I

Professional

Both

$264.00

Service Code	HCPCS 75716 TC
Min. Negotiated Rate	$82.04
Max. Negotiated Rate	$626.28
Rate for Payer: AlohaCare Medicaid	$103.42
Rate for Payer: AlohaCare Medicare	$82.04
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Devoted Health Medicare	$90.24
Rate for Payer: Hawaii Medical Service Association Medicare	$82.04
Rate for Payer: Hawaii Western Management Group Commercial	$626.28
Rate for Payer: Health Management Network Commercial	$224.40
Rate for Payer: Kaiser Permanente Commercial	$98.45
Rate for Payer: Kaiser Permanente Medicaid	$98.45
Rate for Payer: Kaiser Permanente Medicare	$98.45
Rate for Payer: Ohana Health Plan Medicaid	$103.42
Rate for Payer: Ohana Health Plan Medicare	$82.04
Rate for Payer: UnitedHealthcare Medicaid	$103.42
Rate for Payer: UnitedHealthcare Medicare	$82.04

CHG ANGIOGRAPHY EXTREMITY BILATERAL RS&I

Professional

Both

$157.00

Service Code	HCPCS 75716 26
Min. Negotiated Rate	$89.84
Max. Negotiated Rate	$626.28
Rate for Payer: AlohaCare Medicaid	$103.42
Rate for Payer: AlohaCare Medicare	$89.84
Rate for Payer: Cash Price	$94.20
Rate for Payer: Cash Price	$94.20
Rate for Payer: Devoted Health Medicare	$98.82
Rate for Payer: Hawaii Medical Service Association Medicare	$89.84
Rate for Payer: Hawaii Western Management Group Commercial	$626.28
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Kaiser Permanente Commercial	$107.81
Rate for Payer: Kaiser Permanente Medicaid	$107.81
Rate for Payer: Kaiser Permanente Medicare	$107.81
Rate for Payer: Ohana Health Plan Medicaid	$103.42
Rate for Payer: Ohana Health Plan Medicare	$89.84
Rate for Payer: UnitedHealthcare Medicaid	$103.42
Rate for Payer: UnitedHealthcare Medicare	$89.84

CHG ANGIOGRAPHY EXTREMITY UNILATERAL RS&I

Professional

Both

$139.00

Service Code	HCPCS 75710 26
Min. Negotiated Rate	$79.41
Max. Negotiated Rate	$616.96
Rate for Payer: AlohaCare Medicaid	$95.12
Rate for Payer: AlohaCare Medicare	$79.41
Rate for Payer: Cash Price	$83.40
Rate for Payer: Cash Price	$83.40
Rate for Payer: Devoted Health Medicare	$87.35
Rate for Payer: Hawaii Medical Service Association Medicare	$79.41
Rate for Payer: Hawaii Western Management Group Commercial	$616.96
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$95.29
Rate for Payer: Kaiser Permanente Medicaid	$95.29
Rate for Payer: Kaiser Permanente Medicare	$95.29
Rate for Payer: Ohana Health Plan Medicaid	$95.12
Rate for Payer: Ohana Health Plan Medicare	$79.41
Rate for Payer: UnitedHealthcare Medicaid	$95.12
Rate for Payer: UnitedHealthcare Medicare	$79.41

CHG ANGIOGRAPHY EXTREMITY UNILATERAL RS&I

Professional

Both

$248.00

Service Code	HCPCS 75710 TC
Min. Negotiated Rate	$77.86
Max. Negotiated Rate	$616.96
Rate for Payer: AlohaCare Medicaid	$95.12
Rate for Payer: AlohaCare Medicare	$77.86
Rate for Payer: Cash Price	$148.80
Rate for Payer: Cash Price	$148.80
Rate for Payer: Devoted Health Medicare	$85.65
Rate for Payer: Hawaii Medical Service Association Medicare	$77.86
Rate for Payer: Hawaii Western Management Group Commercial	$616.96
Rate for Payer: Health Management Network Commercial	$210.80
Rate for Payer: Kaiser Permanente Commercial	$93.43
Rate for Payer: Kaiser Permanente Medicaid	$93.43
Rate for Payer: Kaiser Permanente Medicare	$93.43
Rate for Payer: Ohana Health Plan Medicaid	$95.12
Rate for Payer: Ohana Health Plan Medicare	$77.86
Rate for Payer: UnitedHealthcare Medicaid	$95.12
Rate for Payer: UnitedHealthcare Medicare	$77.86

CHG ANGIOGRAPHY EXTREMITY UNILATERAL RS&I

Professional

Both

$387.00

Service Code	HCPCS 75710
Min. Negotiated Rate	$95.12
Max. Negotiated Rate	$616.96
Rate for Payer: AlohaCare Medicaid	$95.12
Rate for Payer: AlohaCare Medicare	$157.27
Rate for Payer: Cash Price	$232.20
Rate for Payer: Cash Price	$232.20
Rate for Payer: Devoted Health Medicare	$173.00
Rate for Payer: Hawaii Medical Service Association Medicare	$157.27
Rate for Payer: Hawaii Western Management Group Commercial	$616.96
Rate for Payer: Health Management Network Commercial	$328.95
Rate for Payer: Kaiser Permanente Commercial	$188.72
Rate for Payer: Kaiser Permanente Medicaid	$188.72
Rate for Payer: Kaiser Permanente Medicare	$188.72
Rate for Payer: Ohana Health Plan Medicaid	$95.12
Rate for Payer: Ohana Health Plan Medicare	$157.27
Rate for Payer: UnitedHealthcare Medicaid	$95.12
Rate for Payer: UnitedHealthcare Medicare	$157.27

CHG ANGIOGRAPHY INTERNAL MAMMARY RS&I

Professional

Both

$227.00

Service Code	HCPCS 75756 TC
Min. Negotiated Rate	$108.56
Max. Negotiated Rate	$618.50
Rate for Payer: AlohaCare Medicaid	$108.56
Rate for Payer: AlohaCare Medicare	$128.18
Rate for Payer: Cash Price	$136.20
Rate for Payer: Cash Price	$136.20
Rate for Payer: Devoted Health Medicare	$141.00
Rate for Payer: Hawaii Medical Service Association Medicare	$128.18
Rate for Payer: Hawaii Western Management Group Commercial	$618.50
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$153.82
Rate for Payer: Kaiser Permanente Medicaid	$153.82
Rate for Payer: Kaiser Permanente Medicare	$153.82
Rate for Payer: Ohana Health Plan Medicaid	$108.56
Rate for Payer: Ohana Health Plan Medicare	$128.18
Rate for Payer: UnitedHealthcare Medicaid	$108.56
Rate for Payer: UnitedHealthcare Medicare	$128.18

CHG ANGIOGRAPHY INTERNAL MAMMARY RS&I

Professional

Both

$319.00

Service Code	HCPCS 75756
Min. Negotiated Rate	$108.56
Max. Negotiated Rate	$618.50
Rate for Payer: AlohaCare Medicaid	$108.56
Rate for Payer: AlohaCare Medicare	$182.39
Rate for Payer: Cash Price	$191.40
Rate for Payer: Cash Price	$191.40
Rate for Payer: Devoted Health Medicare	$200.63
Rate for Payer: Hawaii Medical Service Association Medicare	$182.39
Rate for Payer: Hawaii Western Management Group Commercial	$618.50
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$218.87
Rate for Payer: Kaiser Permanente Medicaid	$218.87
Rate for Payer: Kaiser Permanente Medicare	$218.87
Rate for Payer: Ohana Health Plan Medicaid	$108.56
Rate for Payer: Ohana Health Plan Medicare	$182.39
Rate for Payer: UnitedHealthcare Medicaid	$108.56
Rate for Payer: UnitedHealthcare Medicare	$182.39

CHG ANGIOGRAPHY INTERNAL MAMMARY RS&I

Professional

Both

$92.00

Service Code	HCPCS 75756 26
Min. Negotiated Rate	$54.21
Max. Negotiated Rate	$618.50
Rate for Payer: AlohaCare Medicaid	$108.56
Rate for Payer: AlohaCare Medicare	$54.21
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Devoted Health Medicare	$59.63
Rate for Payer: Hawaii Medical Service Association Medicare	$54.21
Rate for Payer: Hawaii Western Management Group Commercial	$618.50
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$65.05
Rate for Payer: Kaiser Permanente Medicaid	$65.05
Rate for Payer: Kaiser Permanente Medicare	$65.05
Rate for Payer: Ohana Health Plan Medicaid	$108.56
Rate for Payer: Ohana Health Plan Medicare	$54.21
Rate for Payer: UnitedHealthcare Medicaid	$108.56
Rate for Payer: UnitedHealthcare Medicare	$54.21

CHG ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I

Professional

Both

$436.00

Service Code	HCPCS 75736
Min. Negotiated Rate	$93.88
Max. Negotiated Rate	$616.76
Rate for Payer: AlohaCare Medicaid	$93.88
Rate for Payer: AlohaCare Medicare	$155.79
Rate for Payer: Cash Price	$261.60
Rate for Payer: Cash Price	$261.60
Rate for Payer: Devoted Health Medicare	$171.37
Rate for Payer: Hawaii Medical Service Association Medicare	$155.79
Rate for Payer: Hawaii Western Management Group Commercial	$616.76
Rate for Payer: Health Management Network Commercial	$370.60
Rate for Payer: Kaiser Permanente Commercial	$186.95
Rate for Payer: Kaiser Permanente Medicaid	$186.95
Rate for Payer: Kaiser Permanente Medicare	$186.95
Rate for Payer: Ohana Health Plan Medicaid	$93.88
Rate for Payer: Ohana Health Plan Medicare	$155.79
Rate for Payer: UnitedHealthcare Medicaid	$93.88
Rate for Payer: UnitedHealthcare Medicare	$155.79

CHG ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I

Professional

Both

$348.00

Service Code	HCPCS 75736 TC
Min. Negotiated Rate	$93.88
Max. Negotiated Rate	$616.76
Rate for Payer: AlohaCare Medicaid	$93.88
Rate for Payer: AlohaCare Medicare	$105.40
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Devoted Health Medicare	$115.94
Rate for Payer: Hawaii Medical Service Association Medicare	$105.40
Rate for Payer: Hawaii Western Management Group Commercial	$616.76
Rate for Payer: Health Management Network Commercial	$295.80
Rate for Payer: Kaiser Permanente Commercial	$126.48
Rate for Payer: Kaiser Permanente Medicaid	$126.48
Rate for Payer: Kaiser Permanente Medicare	$126.48
Rate for Payer: Ohana Health Plan Medicaid	$93.88
Rate for Payer: Ohana Health Plan Medicare	$105.40
Rate for Payer: UnitedHealthcare Medicaid	$93.88
Rate for Payer: UnitedHealthcare Medicare	$105.40

CHG ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I

Professional

Both

$88.00

Service Code	HCPCS 75736 26
Min. Negotiated Rate	$50.39
Max. Negotiated Rate	$616.76
Rate for Payer: AlohaCare Medicaid	$93.88
Rate for Payer: AlohaCare Medicare	$50.39
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Devoted Health Medicare	$55.43
Rate for Payer: Hawaii Medical Service Association Medicare	$50.39
Rate for Payer: Hawaii Western Management Group Commercial	$616.76
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Kaiser Permanente Commercial	$60.47
Rate for Payer: Kaiser Permanente Medicaid	$60.47
Rate for Payer: Kaiser Permanente Medicare	$60.47
Rate for Payer: Ohana Health Plan Medicaid	$93.88
Rate for Payer: Ohana Health Plan Medicare	$50.39
Rate for Payer: UnitedHealthcare Medicaid	$93.88
Rate for Payer: UnitedHealthcare Medicare	$50.39

CHG ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I

Professional

Both

$272.90

Service Code	HCPCS 75743
Min. Negotiated Rate	$94.85
Max. Negotiated Rate	$645.23
Rate for Payer: AlohaCare Medicaid	$94.85
Rate for Payer: AlohaCare Medicare	$155.94
Rate for Payer: Cash Price	$163.74
Rate for Payer: Cash Price	$163.74
Rate for Payer: Devoted Health Medicare	$171.53
Rate for Payer: Hawaii Medical Service Association Medicare	$155.94
Rate for Payer: Hawaii Western Management Group Commercial	$645.23
Rate for Payer: Health Management Network Commercial	$231.97
Rate for Payer: Kaiser Permanente Commercial	$187.13
Rate for Payer: Kaiser Permanente Medicaid	$187.13
Rate for Payer: Kaiser Permanente Medicare	$187.13
Rate for Payer: Ohana Health Plan Medicaid	$94.85
Rate for Payer: Ohana Health Plan Medicare	$155.94
Rate for Payer: UnitedHealthcare Medicaid	$94.85
Rate for Payer: UnitedHealthcare Medicare	$155.94

CHG ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I

Professional

Both

$131.00

Service Code	HCPCS 75743 26
Min. Negotiated Rate	$75.04
Max. Negotiated Rate	$645.23
Rate for Payer: AlohaCare Medicaid	$94.85
Rate for Payer: AlohaCare Medicare	$75.04
Rate for Payer: Cash Price	$78.60
Rate for Payer: Cash Price	$78.60
Rate for Payer: Devoted Health Medicare	$82.54
Rate for Payer: Hawaii Medical Service Association Medicare	$75.04
Rate for Payer: Hawaii Western Management Group Commercial	$645.23
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$90.05
Rate for Payer: Kaiser Permanente Medicaid	$90.05
Rate for Payer: Kaiser Permanente Medicare	$90.05
Rate for Payer: Ohana Health Plan Medicaid	$94.85
Rate for Payer: Ohana Health Plan Medicare	$75.04
Rate for Payer: UnitedHealthcare Medicaid	$94.85
Rate for Payer: UnitedHealthcare Medicare	$75.04

CHG ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I

Professional

Both

$142.00

Service Code	HCPCS 75743 TC
Min. Negotiated Rate	$80.90
Max. Negotiated Rate	$645.23
Rate for Payer: AlohaCare Medicaid	$94.85
Rate for Payer: AlohaCare Medicare	$80.90
Rate for Payer: Cash Price	$85.20
Rate for Payer: Cash Price	$85.20
Rate for Payer: Devoted Health Medicare	$88.99
Rate for Payer: Hawaii Medical Service Association Medicare	$80.90
Rate for Payer: Hawaii Western Management Group Commercial	$645.23
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$97.08
Rate for Payer: Kaiser Permanente Medicaid	$97.08
Rate for Payer: Kaiser Permanente Medicare	$97.08
Rate for Payer: Ohana Health Plan Medicaid	$94.85
Rate for Payer: Ohana Health Plan Medicare	$80.90
Rate for Payer: UnitedHealthcare Medicaid	$94.85
Rate for Payer: UnitedHealthcare Medicare	$80.90

Know your out-of-pocket cost for care.

All Charges