Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

TX OF WOUND DEHISCENCE SIMPLE CHARGE

Facility

$2,091.00

Service Code	HCPCS 12020
Hospital Charge Code	440120200
Hospital Revenue Code	450
Min. Negotiated Rate	$1,777.35
Max. Negotiated Rate	$2,028.27
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: MDX Hawaii PPO	$2,028.27

TX OF WOUND DEHISCENCE SIMPLE CHARGE

Facility

$2,091.00

Service Code	HCPCS 12020
Hospital Charge Code	440120200
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$2,028.27
Rate for Payer: AlohaCare Medicaid	$1,045.50
Rate for Payer: AlohaCare Medicare	$878.22
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,923.72
Rate for Payer: Devoted Health Medicare	$878.22
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	$878.22
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.45
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Humana Medicare	$878.22
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$878.22
Rate for Payer: MDX Hawaii PPO	$2,028.27
Rate for Payer: Ohana Health Plan Medicaid	$878.22
Rate for Payer: Ohana Health Plan Medicare	$878.22
Rate for Payer: UnitedHealthcare Medicare	$878.22
Rate for Payer: University Health Alliance Commercial	$1,524.13

TX SHOULDER DISLOCATED-W/ANES CL Charge

Facility

$5,895.00

Service Code	HCPCS 23655
Hospital Charge Code	440236550
Hospital Revenue Code	450
Min. Negotiated Rate	$5,010.75
Max. Negotiated Rate	$5,718.15
Rate for Payer: Cash Price	$3,831.75
Rate for Payer: Health Management Network Commercial	$5,010.75
Rate for Payer: Kaiser Permanente Commercial	$5,305.50
Rate for Payer: MDX Hawaii PPO	$5,718.15

TX SHOULDER DISLOCATED-W/ANES CL Charge

Facility

$5,895.00

Service Code	HCPCS 23655
Hospital Charge Code	440236550
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$5,718.15
Rate for Payer: AlohaCare Medicaid	$2,947.50
Rate for Payer: AlohaCare Medicare	$2,475.90
Rate for Payer: Cash Price	$3,831.75
Rate for Payer: Cash Price	$3,831.75
Rate for Payer: Cash Price	$3,831.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,423.40
Rate for Payer: Devoted Health Medicare	$2,475.90
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	$2,475.90
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.25
Rate for Payer: Health Management Network Commercial	$5,010.75
Rate for Payer: Humana Medicare	$2,475.90
Rate for Payer: Kaiser Permanente Commercial	$5,305.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,475.90
Rate for Payer: MDX Hawaii PPO	$5,718.15
Rate for Payer: Ohana Health Plan Medicaid	$2,475.90
Rate for Payer: Ohana Health Plan Medicare	$2,475.90
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,475.90
Rate for Payer: University Health Alliance Commercial	$4,035.20

TX SHOULDER DISLOCATED W/O ANES Charge

Facility

$887.00

Service Code	HCPCS 23650
Hospital Charge Code	440236500
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

TX SHOULDER DISLOCATED W/O ANES Charge

Facility

$887.00

Service Code	HCPCS 23650
Hospital Charge Code	440236500
Hospital Revenue Code	450
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

TX SHOULDER SEPARATION Charge

Facility

$887.00

Service Code	HCPCS 23540
Hospital Charge Code	440235400
Hospital Revenue Code	450
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

TX SHOULDER SEPARATION Charge

Facility

$887.00

Service Code	HCPCS 23540
Hospital Charge Code	440235400
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

TX SHOULDER W/MAN-CLOSED Charge

Facility

$887.00

Service Code	HCPCS 23545
Hospital Charge Code	440235450
Hospital Revenue Code	450
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

TX SHOULDER W/MAN-CLOSED Charge

Facility

$887.00

Service Code	HCPCS 23545
Hospital Charge Code	440235450
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

TX SPEECH LANG VOICE COMMJ&/AUD PROC DO INDIV

Professional

Both

$321.00

Service Code	HCPCS 92507
Hospital Revenue Code	440
Min. Negotiated Rate	$36.92
Max. Negotiated Rate	$272.85
Rate for Payer: AlohaCare Medicaid	$80.55
Rate for Payer: AlohaCare Medicare	$80.45
Rate for Payer: Cash Price	$208.65
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$80.45
Rate for Payer: Hawaii Medical Service Association Commercial	$36.92
Rate for Payer: Hawaii Medical Service Association Medicare	$80.45
Rate for Payer: Hawaii Western Management Group Commercial	$37.04
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$96.54
Rate for Payer: Kaiser Permanente Medicaid	$96.54
Rate for Payer: Kaiser Permanente Medicare	$96.54
Rate for Payer: Ohana Health Plan Medicaid	$80.55
Rate for Payer: Ohana Health Plan Medicare	$80.45
Rate for Payer: UnitedHealthcare Medicaid	$80.55
Rate for Payer: UnitedHealthcare Medicare	$80.45

TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE

Professional

Both

$1,495.00

Service Code	HCPCS 12020
Hospital Revenue Code	361
Min. Negotiated Rate	$76.44
Max. Negotiated Rate	$1,270.75
Rate for Payer: AlohaCare Medicaid	$195.02
Rate for Payer: AlohaCare Medicare	$183.26
Rate for Payer: Cash Price	$971.75
Rate for Payer: Cash Price	$971.75
Rate for Payer: Devoted Health Medicare	$183.26
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$195.02
Rate for Payer: Hawaii Medical Service Association Commercial	$299.12
Rate for Payer: Hawaii Medical Service Association Medicare	$183.26
Rate for Payer: Hawaii Western Management Group Commercial	$76.44
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Kaiser Permanente Commercial	$219.91
Rate for Payer: Kaiser Permanente Medicaid	$219.91
Rate for Payer: Kaiser Permanente Medicare	$219.91
Rate for Payer: Ohana Health Plan Medicaid	$195.02
Rate for Payer: Ohana Health Plan Medicare	$183.26
Rate for Payer: UnitedHealthcare Medicaid	$195.02
Rate for Payer: UnitedHealthcare Medicare	$183.26
Rate for Payer: University Health Alliance Commercial	$212.61

TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING

Professional

Both

$379.00

Service Code	HCPCS 92526
Hospital Revenue Code	440
Min. Negotiated Rate	$33.86
Max. Negotiated Rate	$322.15
Rate for Payer: AlohaCare Medicaid	$89.91
Rate for Payer: AlohaCare Medicare	$89.38
Rate for Payer: Cash Price	$246.35
Rate for Payer: Cash Price	$246.35
Rate for Payer: Devoted Health Medicare	$89.38
Rate for Payer: Hawaii Medical Service Association Commercial	$36.77
Rate for Payer: Hawaii Medical Service Association Medicare	$89.38
Rate for Payer: Hawaii Western Management Group Commercial	$33.86
Rate for Payer: Health Management Network Commercial	$322.15
Rate for Payer: Kaiser Permanente Commercial	$107.26
Rate for Payer: Kaiser Permanente Medicaid	$107.26
Rate for Payer: Kaiser Permanente Medicare	$107.26
Rate for Payer: Ohana Health Plan Medicaid	$89.91
Rate for Payer: Ohana Health Plan Medicare	$89.38
Rate for Payer: UnitedHealthcare Medicaid	$89.91
Rate for Payer: UnitedHealthcare Medicare	$89.38

TX THUMB DISLOCATION Charge

Facility

$887.00

Service Code	HCPCS 26641
Hospital Charge Code	440266410
Hospital Revenue Code	450
Min. Negotiated Rate	$753.95
Max. Negotiated Rate	$860.39
Rate for Payer: Cash Price	$576.55
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: MDX Hawaii PPO	$860.39

TX THUMB DISLOCATION Charge

Facility

$887.00

Service Code	HCPCS 26641
Hospital Charge Code	440266410
Hospital Revenue Code	450
Min. Negotiated Rate	$372.54
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$443.50
Rate for Payer: AlohaCare Medicare	$372.54
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Cash Price	$576.55
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$816.04
Rate for Payer: Devoted Health Medicare	$372.54
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	$372.54
Rate for Payer: Hawaii Western Management Group Commercial	$842.65
Rate for Payer: Health Management Network Commercial	$753.95
Rate for Payer: Humana Medicare	$372.54
Rate for Payer: Kaiser Permanente Commercial	$798.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$372.54
Rate for Payer: MDX Hawaii PPO	$860.39
Rate for Payer: Ohana Health Plan Medicaid	$372.54
Rate for Payer: Ohana Health Plan Medicare	$372.54
Rate for Payer: UnitedHealthcare Medicare	$372.54
Rate for Payer: University Health Alliance Commercial	$646.53

Type and Screen 6

Facility

$1,063.00

Service Code	HCPCS 86902
Hospital Charge Code	422869020
Hospital Revenue Code	302
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$1,031.11
Rate for Payer: AlohaCare Medicaid	$531.50
Rate for Payer: AlohaCare Medicare	$446.46
Rate for Payer: Cash Price	$690.95
Rate for Payer: Cash Price	$690.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$977.96
Rate for Payer: Devoted Health Medicare	$446.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.38
Rate for Payer: Hawaii Medical Service Association Commercial	$7.94
Rate for Payer: Hawaii Medical Service Association Medicare	$446.46
Rate for Payer: Hawaii Western Management Group Commercial	$6.35
Rate for Payer: Health Management Network Commercial	$903.55
Rate for Payer: Humana Medicare	$446.46
Rate for Payer: Kaiser Permanente Commercial	$956.70
Rate for Payer: Kaiser Permanente Medicaid	$542.13
Rate for Payer: Kaiser Permanente Medicare	$446.46
Rate for Payer: MDX Hawaii PPO	$1,031.11
Rate for Payer: Ohana Health Plan Medicaid	$446.46
Rate for Payer: Ohana Health Plan Medicare	$446.46
Rate for Payer: UnitedHealthcare Medicaid	$5.38
Rate for Payer: UnitedHealthcare Medicare	$446.46
Rate for Payer: University Health Alliance Commercial	$9.95

Type and Screen 6

Facility

$1,063.00

Service Code	HCPCS 86902
Hospital Charge Code	422869020
Hospital Revenue Code	302
Min. Negotiated Rate	$903.55
Max. Negotiated Rate	$1,031.11
Rate for Payer: Cash Price	$690.95
Rate for Payer: Health Management Network Commercial	$903.55
Rate for Payer: Kaiser Permanente Commercial	$956.70
Rate for Payer: MDX Hawaii PPO	$1,031.11

Type & Screen 2

Facility

$1,063.00

Service Code	HCPCS 86902
Hospital Charge Code	422869020
Hospital Revenue Code	302
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$1,031.11
Rate for Payer: AlohaCare Medicaid	$531.50
Rate for Payer: AlohaCare Medicare	$446.46
Rate for Payer: Cash Price	$690.95
Rate for Payer: Cash Price	$690.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$977.96
Rate for Payer: Devoted Health Medicare	$446.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$5.38
Rate for Payer: Hawaii Medical Service Association Commercial	$7.94
Rate for Payer: Hawaii Medical Service Association Medicare	$446.46
Rate for Payer: Hawaii Western Management Group Commercial	$6.35
Rate for Payer: Health Management Network Commercial	$903.55
Rate for Payer: Humana Medicare	$446.46
Rate for Payer: Kaiser Permanente Commercial	$956.70
Rate for Payer: Kaiser Permanente Medicaid	$542.13
Rate for Payer: Kaiser Permanente Medicare	$446.46
Rate for Payer: MDX Hawaii PPO	$1,031.11
Rate for Payer: Ohana Health Plan Medicaid	$446.46
Rate for Payer: Ohana Health Plan Medicare	$446.46
Rate for Payer: UnitedHealthcare Medicaid	$5.38
Rate for Payer: UnitedHealthcare Medicare	$446.46
Rate for Payer: University Health Alliance Commercial	$9.95

Type & Screen 2

Facility

$1,063.00

Service Code	HCPCS 86902
Hospital Charge Code	422869020
Hospital Revenue Code	302
Min. Negotiated Rate	$903.55
Max. Negotiated Rate	$1,031.11
Rate for Payer: Cash Price	$690.95
Rate for Payer: Health Management Network Commercial	$903.55
Rate for Payer: Kaiser Permanente Commercial	$956.70
Rate for Payer: MDX Hawaii PPO	$1,031.11

UA, Complete, w/ Reflex to C&S DLS

Facility

$30.00

Service Code	HCPCS 81001
Hospital Charge Code	422810015
Hospital Revenue Code	307
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$29.10
Rate for Payer: Cash Price	$19.50
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: MDX Hawaii PPO	$29.10

UA, Complete, w/ Reflex to C&S DLS

Facility

$30.00

Service Code	HCPCS 81001
Hospital Charge Code	422810015
Hospital Revenue Code	307
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$29.10
Rate for Payer: AlohaCare Medicaid	$15.00
Rate for Payer: AlohaCare Medicare	$12.60
Rate for Payer: Cash Price	$19.50
Rate for Payer: Cash Price	$19.50
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$27.60
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$4.37
Rate for Payer: Hawaii Medical Service Association Commercial	$3.96
Rate for Payer: Hawaii Medical Service Association Medicare	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$3.17
Rate for Payer: Health Management Network Commercial	$25.50
Rate for Payer: Humana Medicare	$12.60
Rate for Payer: Kaiser Permanente Commercial	$27.00
Rate for Payer: Kaiser Permanente Medicaid	$15.30
Rate for Payer: Kaiser Permanente Medicare	$12.60
Rate for Payer: MDX Hawaii PPO	$29.10
Rate for Payer: Ohana Health Plan Medicaid	$12.60
Rate for Payer: Ohana Health Plan Medicare	$12.60
Rate for Payer: UnitedHealthcare Medicaid	$4.37
Rate for Payer: UnitedHealthcare Medicare	$12.60
Rate for Payer: University Health Alliance Commercial	$8.20

UC PRO DRAIN ABSCESS CYST Charge

Facility

$816.00

Service Code	HCPCS 40800
Hospital Charge Code	440408000
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$408.00
Rate for Payer: AlohaCare Medicare	$342.72
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Cash Price	$530.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$750.72
Rate for Payer: Devoted Health Medicare	$342.72
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	$342.72
Rate for Payer: Hawaii Western Management Group Commercial	$775.20
Rate for Payer: Health Management Network Commercial	$693.60
Rate for Payer: Humana Medicare	$342.72
Rate for Payer: Kaiser Permanente Commercial	$734.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$342.72
Rate for Payer: MDX Hawaii PPO	$791.52
Rate for Payer: Ohana Health Plan Medicaid	$342.72
Rate for Payer: Ohana Health Plan Medicare	$342.72
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$342.72
Rate for Payer: University Health Alliance Commercial	$594.78

UC PRO DRAIN ABSCESS CYST Charge

Facility

$816.00

Service Code	HCPCS 40800
Hospital Charge Code	440408000
Hospital Revenue Code	450
Min. Negotiated Rate	$693.60
Max. Negotiated Rate	$791.52
Rate for Payer: Cash Price	$530.40
Rate for Payer: Health Management Network Commercial	$693.60
Rate for Payer: Kaiser Permanente Commercial	$734.40
Rate for Payer: MDX Hawaii PPO	$791.52

UC PROF RMV FB, MOUTH EMB Charge

Facility

$503.00

Service Code	HCPCS 40804
Hospital Charge Code	440408040
Hospital Revenue Code	450
Min. Negotiated Rate	$211.26
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$251.50
Rate for Payer: AlohaCare Medicare	$211.26
Rate for Payer: Cash Price	$326.95
Rate for Payer: Cash Price	$326.95
Rate for Payer: Cash Price	$326.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$462.76
Rate for Payer: Devoted Health Medicare	$211.26
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	$211.26
Rate for Payer: Hawaii Western Management Group Commercial	$477.85
Rate for Payer: Health Management Network Commercial	$427.55
Rate for Payer: Humana Medicare	$211.26
Rate for Payer: Kaiser Permanente Commercial	$452.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$211.26
Rate for Payer: MDX Hawaii PPO	$487.91
Rate for Payer: Ohana Health Plan Medicaid	$211.26
Rate for Payer: Ohana Health Plan Medicare	$211.26
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$211.26
Rate for Payer: University Health Alliance Commercial	$366.64

UC PROF RMV FB, MOUTH EMB Charge

Facility

$503.00

Service Code	HCPCS 40804
Hospital Charge Code	440408040
Hospital Revenue Code	450
Min. Negotiated Rate	$427.55
Max. Negotiated Rate	$487.91
Rate for Payer: Cash Price	$326.95
Rate for Payer: Health Management Network Commercial	$427.55
Rate for Payer: Kaiser Permanente Commercial	$452.70
Rate for Payer: MDX Hawaii PPO	$487.91

Know your out-of-pocket cost for care.

All Charges