Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

ARIPiprazole 300 mg ER prefilled syringe [KMC]

Facility

$8,598.48

Service Code	HCPCS J0401
Hospital Revenue Code	636
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$8,340.53
Rate for Payer: AlohaCare Medicaid	$4,299.24
Rate for Payer: AlohaCare Medicare	$3,611.36
Rate for Payer: Cash Price	$5,589.01
Rate for Payer: Cash Price	$5,589.01
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7,910.60
Rate for Payer: Devoted Health Medicare	$3,611.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.24
Rate for Payer: Hawaii Medical Service Association Commercial	$9.09
Rate for Payer: Hawaii Medical Service Association Medicare	$3,611.36
Rate for Payer: Hawaii Western Management Group Commercial	$8,168.56
Rate for Payer: Health Management Network Commercial	$7,308.71
Rate for Payer: Humana Medicare	$3,611.36
Rate for Payer: Kaiser Permanente Commercial	$7,738.63
Rate for Payer: Kaiser Permanente Medicaid	$4,385.22
Rate for Payer: Kaiser Permanente Medicare	$3,611.36
Rate for Payer: MDX Hawaii PPO	$8,340.53
Rate for Payer: Ohana Health Plan Medicaid	$3,611.36
Rate for Payer: Ohana Health Plan Medicare	$3,611.36
Rate for Payer: UnitedHealthcare Medicaid	$5,159.09
Rate for Payer: UnitedHealthcare Medicare	$3,611.36
Rate for Payer: University Health Alliance Commercial	$6,267.43

ARIPiprazole 300 mg ER prefilled syringe [KMC]

Facility

$8,598.48

Service Code	HCPCS J0401
Hospital Revenue Code	636
Min. Negotiated Rate	$7,308.71
Max. Negotiated Rate	$8,340.53
Rate for Payer: Cash Price	$5,589.01
Rate for Payer: Health Management Network Commercial	$7,308.71
Rate for Payer: Kaiser Permanente Commercial	$7,738.63
Rate for Payer: MDX Hawaii PPO	$8,340.53

ARIPiprazole 400 mg pre-filled syringe [KMC]

Facility

$11,464.64

Service Code	HCPCS J0401
Hospital Revenue Code	636
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$11,120.70
Rate for Payer: AlohaCare Medicaid	$5,732.32
Rate for Payer: AlohaCare Medicare	$4,815.15
Rate for Payer: Cash Price	$7,452.02
Rate for Payer: Cash Price	$7,452.02
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$10,547.47
Rate for Payer: Devoted Health Medicare	$4,815.15
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.24
Rate for Payer: Hawaii Medical Service Association Commercial	$9.09
Rate for Payer: Hawaii Medical Service Association Medicare	$4,815.15
Rate for Payer: Hawaii Western Management Group Commercial	$10,891.41
Rate for Payer: Health Management Network Commercial	$9,744.94
Rate for Payer: Humana Medicare	$4,815.15
Rate for Payer: Kaiser Permanente Commercial	$10,318.18
Rate for Payer: Kaiser Permanente Medicaid	$5,846.97
Rate for Payer: Kaiser Permanente Medicare	$4,815.15
Rate for Payer: MDX Hawaii PPO	$11,120.70
Rate for Payer: Ohana Health Plan Medicaid	$4,815.15
Rate for Payer: Ohana Health Plan Medicare	$4,815.15
Rate for Payer: UnitedHealthcare Medicaid	$6,878.78
Rate for Payer: UnitedHealthcare Medicare	$4,815.15
Rate for Payer: University Health Alliance Commercial	$8,356.58

ARIPiprazole 400 mg pre-filled syringe [KMC]

Facility

$11,464.64

Service Code	HCPCS J0401
Hospital Revenue Code	636
Min. Negotiated Rate	$9,744.94
Max. Negotiated Rate	$11,120.70
Rate for Payer: Cash Price	$7,452.02
Rate for Payer: Health Management Network Commercial	$9,744.94
Rate for Payer: Kaiser Permanente Commercial	$10,318.18
Rate for Payer: MDX Hawaii PPO	$11,120.70

ARIPiprazole 5 mg Tab [KMC]

Facility

$127.30

Service Code	NDC 16714014201
Hospital Revenue Code	250
Min. Negotiated Rate	$53.47
Max. Negotiated Rate	$123.48
Rate for Payer: AlohaCare Medicaid	$63.65
Rate for Payer: AlohaCare Medicare	$53.47
Rate for Payer: Cash Price	$82.74
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$117.12
Rate for Payer: Devoted Health Medicare	$53.47
Rate for Payer: Hawaii Medical Service Association Medicare	$53.47
Rate for Payer: Hawaii Western Management Group Commercial	$120.94
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Humana Medicare	$53.47
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: Kaiser Permanente Medicaid	$64.92
Rate for Payer: Kaiser Permanente Medicare	$53.47
Rate for Payer: MDX Hawaii PPO	$123.48
Rate for Payer: Ohana Health Plan Medicaid	$53.47
Rate for Payer: Ohana Health Plan Medicare	$53.47
Rate for Payer: UnitedHealthcare Medicaid	$76.38
Rate for Payer: UnitedHealthcare Medicare	$53.47
Rate for Payer: University Health Alliance Commercial	$92.79

ARIPiprazole 5 mg Tab [KMC]

Facility

$127.30

Service Code	NDC 16714014201
Hospital Revenue Code	250
Min. Negotiated Rate	$108.20
Max. Negotiated Rate	$123.48
Rate for Payer: Cash Price	$82.74
Rate for Payer: Health Management Network Commercial	$108.20
Rate for Payer: Kaiser Permanente Commercial	$114.57
Rate for Payer: MDX Hawaii PPO	$123.48

ARMBOARD LG 3.25" X 18"

Facility

$17.00

Hospital Charge Code	8026
Hospital Revenue Code	270
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$7.14
Rate for Payer: Cash Price	$11.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.64
Rate for Payer: Devoted Health Medicare	$7.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.14
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$7.14
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$7.14
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$7.14
Rate for Payer: Ohana Health Plan Medicare	$7.14
Rate for Payer: UnitedHealthcare Medicare	$7.14
Rate for Payer: University Health Alliance Commercial	$12.39

ARMBOARD LG 3.25" X 18"

Facility

$17.00

Hospital Charge Code	8026
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

ARMBOARD SM 3.25" X 9"

Facility

$17.00

Hospital Charge Code	8027
Hospital Revenue Code	270
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$16.49
Rate for Payer: Cash Price	$11.05
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: MDX Hawaii PPO	$16.49

ARMBOARD SM 3.25" X 9"

Facility

$17.00

Hospital Charge Code	8027
Hospital Revenue Code	270
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$16.49
Rate for Payer: AlohaCare Medicaid	$8.50
Rate for Payer: AlohaCare Medicare	$7.14
Rate for Payer: Cash Price	$11.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$15.64
Rate for Payer: Devoted Health Medicare	$7.14
Rate for Payer: Hawaii Medical Service Association Medicare	$7.14
Rate for Payer: Hawaii Western Management Group Commercial	$16.15
Rate for Payer: Health Management Network Commercial	$14.45
Rate for Payer: Humana Medicare	$7.14
Rate for Payer: Kaiser Permanente Commercial	$15.30
Rate for Payer: Kaiser Permanente Medicaid	$8.67
Rate for Payer: Kaiser Permanente Medicare	$7.14
Rate for Payer: MDX Hawaii PPO	$16.49
Rate for Payer: Ohana Health Plan Medicaid	$7.14
Rate for Payer: Ohana Health Plan Medicare	$7.14
Rate for Payer: UnitedHealthcare Medicare	$7.14
Rate for Payer: University Health Alliance Commercial	$12.39

ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX

Professional

Both

$360.00

Service Code	HCPCS 36600
Hospital Revenue Code	300
Min. Negotiated Rate	$13.02
Max. Negotiated Rate	$306.00
Rate for Payer: AlohaCare Medicaid	$14.85
Rate for Payer: AlohaCare Medicare	$13.02
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Devoted Health Medicare	$13.02
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$14.85
Rate for Payer: Hawaii Medical Service Association Commercial	$24.11
Rate for Payer: Hawaii Medical Service Association Medicare	$13.02
Rate for Payer: Hawaii Western Management Group Commercial	$23.40
Rate for Payer: Health Management Network Commercial	$306.00
Rate for Payer: Kaiser Permanente Commercial	$15.62
Rate for Payer: Kaiser Permanente Medicaid	$15.62
Rate for Payer: Kaiser Permanente Medicare	$15.62
Rate for Payer: Ohana Health Plan Medicaid	$14.85
Rate for Payer: Ohana Health Plan Medicare	$13.02
Rate for Payer: UnitedHealthcare Medicaid	$14.85
Rate for Payer: UnitedHealthcare Medicare	$13.02
Rate for Payer: University Health Alliance Commercial	$24.00

ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US

Professional

Both

$196.00

Service Code	HCPCS 20605
Hospital Revenue Code	361
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$166.60
Rate for Payer: AlohaCare Medicaid	$36.94
Rate for Payer: AlohaCare Medicare	$31.95
Rate for Payer: Cash Price	$127.40
Rate for Payer: Cash Price	$127.40
Rate for Payer: Devoted Health Medicare	$31.95
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$36.94
Rate for Payer: Hawaii Medical Service Association Commercial	$57.80
Rate for Payer: Hawaii Medical Service Association Medicare	$31.95
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$166.60
Rate for Payer: Kaiser Permanente Commercial	$38.34
Rate for Payer: Kaiser Permanente Medicaid	$38.34
Rate for Payer: Kaiser Permanente Medicare	$38.34
Rate for Payer: Ohana Health Plan Medicaid	$36.94
Rate for Payer: Ohana Health Plan Medicare	$31.95
Rate for Payer: UnitedHealthcare Medicaid	$36.94
Rate for Payer: UnitedHealthcare Medicare	$31.95
Rate for Payer: University Health Alliance Commercial	$48.93

ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US

Professional

Both

$154.00

Service Code	HCPCS 20610
Hospital Revenue Code	361
Min. Negotiated Rate	$39.25
Max. Negotiated Rate	$130.90
Rate for Payer: AlohaCare Medicaid	$45.55
Rate for Payer: AlohaCare Medicare	$39.25
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Devoted Health Medicare	$39.25
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$45.55
Rate for Payer: Hawaii Medical Service Association Commercial	$70.55
Rate for Payer: Hawaii Medical Service Association Medicare	$39.25
Rate for Payer: Hawaii Western Management Group Commercial	$58.76
Rate for Payer: Health Management Network Commercial	$130.90
Rate for Payer: Kaiser Permanente Commercial	$47.10
Rate for Payer: Kaiser Permanente Medicaid	$47.10
Rate for Payer: Kaiser Permanente Medicare	$47.10
Rate for Payer: Ohana Health Plan Medicaid	$45.55
Rate for Payer: Ohana Health Plan Medicare	$39.25
Rate for Payer: UnitedHealthcare Medicaid	$45.55
Rate for Payer: UnitedHealthcare Medicare	$39.25

ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US

Professional

Both

$307.00

Service Code	HCPCS 20611
Hospital Revenue Code	361
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$260.95
Rate for Payer: AlohaCare Medicaid	$58.92
Rate for Payer: AlohaCare Medicare	$49.46
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$49.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$58.92
Rate for Payer: Hawaii Medical Service Association Commercial	$92.25
Rate for Payer: Hawaii Medical Service Association Medicare	$49.46
Rate for Payer: Hawaii Western Management Group Commercial	$99.32
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Kaiser Permanente Commercial	$59.35
Rate for Payer: Kaiser Permanente Medicaid	$59.35
Rate for Payer: Kaiser Permanente Medicare	$59.35
Rate for Payer: Ohana Health Plan Medicaid	$58.92
Rate for Payer: Ohana Health Plan Medicare	$49.46
Rate for Payer: UnitedHealthcare Medicaid	$58.92
Rate for Payer: UnitedHealthcare Medicare	$49.46
Rate for Payer: University Health Alliance Commercial	$138.00

ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US

Professional

Both

$118.00

Service Code	HCPCS 20600
Hospital Revenue Code	361
Min. Negotiated Rate	$31.28
Max. Negotiated Rate	$100.30
Rate for Payer: AlohaCare Medicaid	$35.89
Rate for Payer: AlohaCare Medicare	$31.28
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$31.28
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$35.89
Rate for Payer: Hawaii Medical Service Association Commercial	$55.56
Rate for Payer: Hawaii Medical Service Association Medicare	$31.28
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$37.54
Rate for Payer: Kaiser Permanente Medicaid	$37.54
Rate for Payer: Kaiser Permanente Medicare	$37.54
Rate for Payer: Ohana Health Plan Medicaid	$35.89
Rate for Payer: Ohana Health Plan Medicare	$31.28
Rate for Payer: UnitedHealthcare Medicaid	$35.89
Rate for Payer: UnitedHealthcare Medicare	$31.28
Rate for Payer: University Health Alliance Commercial	$47.04

ARTHROCENTESIS, MAJ JOINT, PRO CHARGE

Facility

$1,035.00

Service Code	HCPCS 20610
Hospital Charge Code	440206100
Hospital Revenue Code	450
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,003.95
Rate for Payer: Cash Price	$672.75
Rate for Payer: Health Management Network Commercial	$879.75
Rate for Payer: Kaiser Permanente Commercial	$931.50
Rate for Payer: MDX Hawaii PPO	$1,003.95

ARTHROCENTESIS, MAJ JOINT, PRO CHARGE

Facility

$1,035.00

Service Code	HCPCS 20610
Hospital Charge Code	440206100
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$517.50
Rate for Payer: AlohaCare Medicare	$434.70
Rate for Payer: Cash Price	$672.75
Rate for Payer: Cash Price	$672.75
Rate for Payer: Cash Price	$672.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$952.20
Rate for Payer: Devoted Health Medicare	$434.70
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$434.70
Rate for Payer: Hawaii Western Management Group Commercial	$983.25
Rate for Payer: Health Management Network Commercial	$879.75
Rate for Payer: Humana Medicare	$434.70
Rate for Payer: Kaiser Permanente Commercial	$931.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$434.70
Rate for Payer: MDX Hawaii PPO	$1,003.95
Rate for Payer: Ohana Health Plan Medicaid	$434.70
Rate for Payer: Ohana Health Plan Medicare	$434.70
Rate for Payer: UnitedHealthcare Medicare	$434.70
Rate for Payer: University Health Alliance Commercial	$4,035.20

ascorbic acid 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904052361
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

ascorbic acid 500 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904052361
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

ascorbic acid-carbonyl iron 125-65 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 63736012301
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

ascorbic acid-carbonyl iron 125-65 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 63736012301
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

asenapine 10 mg Tab [KMC]

Facility

$86.46

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$73.49
Max. Negotiated Rate	$83.87
Rate for Payer: Cash Price	$56.20
Rate for Payer: Health Management Network Commercial	$73.49
Rate for Payer: Kaiser Permanente Commercial	$77.81
Rate for Payer: MDX Hawaii PPO	$83.87

asenapine 10 mg Tab [KMC]

Facility

$86.46

Service Code	HCPCS A9270
Hospital Revenue Code	637
Min. Negotiated Rate	$36.31
Max. Negotiated Rate	$83.87
Rate for Payer: AlohaCare Medicaid	$43.23
Rate for Payer: AlohaCare Medicare	$36.31
Rate for Payer: Cash Price	$56.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$79.54
Rate for Payer: Devoted Health Medicare	$36.31
Rate for Payer: Hawaii Medical Service Association Medicare	$36.31
Rate for Payer: Hawaii Western Management Group Commercial	$82.14
Rate for Payer: Health Management Network Commercial	$73.49
Rate for Payer: Humana Medicare	$36.31
Rate for Payer: Kaiser Permanente Commercial	$77.81
Rate for Payer: Kaiser Permanente Medicaid	$44.09
Rate for Payer: Kaiser Permanente Medicare	$36.31
Rate for Payer: MDX Hawaii PPO	$83.87
Rate for Payer: Ohana Health Plan Medicaid	$36.31
Rate for Payer: Ohana Health Plan Medicare	$36.31
Rate for Payer: UnitedHealthcare Medicare	$36.31
Rate for Payer: University Health Alliance Commercial	$63.02

ASP/INJ SMALL JOINT Charge

Facility

$1,035.00

Service Code	HCPCS 20600
Hospital Charge Code	440206000
Hospital Revenue Code	450
Min. Negotiated Rate	$879.75
Max. Negotiated Rate	$1,003.95
Rate for Payer: Cash Price	$672.75
Rate for Payer: Health Management Network Commercial	$879.75
Rate for Payer: Kaiser Permanente Commercial	$931.50
Rate for Payer: MDX Hawaii PPO	$1,003.95

ASP/INJ SMALL JOINT Charge

Facility

$1,035.00

Service Code	HCPCS 20600
Hospital Charge Code	440206000
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$517.50
Rate for Payer: AlohaCare Medicare	$434.70
Rate for Payer: Cash Price	$672.75
Rate for Payer: Cash Price	$672.75
Rate for Payer: Cash Price	$672.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$952.20
Rate for Payer: Devoted Health Medicare	$434.70
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$434.70
Rate for Payer: Hawaii Western Management Group Commercial	$983.25
Rate for Payer: Health Management Network Commercial	$879.75
Rate for Payer: Humana Medicare	$434.70
Rate for Payer: Kaiser Permanente Commercial	$931.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$434.70
Rate for Payer: MDX Hawaii PPO	$1,003.95
Rate for Payer: Ohana Health Plan Medicaid	$434.70
Rate for Payer: Ohana Health Plan Medicare	$434.70
Rate for Payer: UnitedHealthcare Medicare	$434.70
Rate for Payer: University Health Alliance Commercial	$754.41

Know your out-of-pocket cost for care.

All Charges