Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR

Facility

$887.00

Service Code	HCPCS 24530
Hospital Charge Code	440245300
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

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR

Facility

$887.00

Service Code	HCPCS 27503
Hospital Charge Code	440275030
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

CLOSED TREATMENT OF TALUS FRACTURE WITHOUT MANIPUL

Facility

$554.00

Service Code	HCPCS 28430
Hospital Charge Code	440284300
Hospital Revenue Code	450
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

CLOSED TREATMENT OF TALUS FRACTURE WITHOUT MANIPUL

Facility

$554.00

Service Code	HCPCS 28430
Hospital Charge Code	440284300
Hospital Revenue Code	450
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$232.68
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$509.68
Rate for Payer: Devoted Health Medicare	$232.68
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	$232.68
Rate for Payer: Hawaii Western Management Group Commercial	$526.30
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$232.68
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$232.68
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$232.68
Rate for Payer: Ohana Health Plan Medicare	$232.68
Rate for Payer: UnitedHealthcare Medicare	$232.68
Rate for Payer: University Health Alliance Commercial	$403.81

CLOSED TREATMENT OF TARSAL BONE FRACTURE WITH MANI

Facility

$554.00

Service Code	HCPCS 28455
Hospital Charge Code	440284550
Hospital Revenue Code	450
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$232.68
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$509.68
Rate for Payer: Devoted Health Medicare	$232.68
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	$232.68
Rate for Payer: Hawaii Western Management Group Commercial	$526.30
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$232.68
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$232.68
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$232.68
Rate for Payer: Ohana Health Plan Medicare	$232.68
Rate for Payer: UnitedHealthcare Medicare	$232.68
Rate for Payer: University Health Alliance Commercial	$403.81

CLOSED TREATMENT OF TARSAL BONE FRACTURE WITH MANI

Facility

$554.00

Service Code	HCPCS 28455
Hospital Charge Code	440284550
Hospital Revenue Code	450
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

CLOSED TREATMENT OF TARSAL BONE FRACTURE WITHOUT M

Facility

$554.00

Service Code	HCPCS 28450
Hospital Charge Code	440284500
Hospital Revenue Code	450
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

CLOSED TREATMENT OF TARSAL BONE FRACTURE WITHOUT M

Facility

$554.00

Service Code	HCPCS 28450
Hospital Charge Code	440284500
Hospital Revenue Code	450
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$232.68
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$509.68
Rate for Payer: Devoted Health Medicare	$232.68
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	$232.68
Rate for Payer: Hawaii Western Management Group Commercial	$526.30
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$232.68
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$232.68
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$232.68
Rate for Payer: Ohana Health Plan Medicare	$232.68
Rate for Payer: UnitedHealthcare Medicare	$232.68
Rate for Payer: University Health Alliance Commercial	$403.81

CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION

Facility

$432.00

Service Code	HCPCS 21480
Hospital Charge Code	440214800
Hospital Revenue Code	450
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: MDX Hawaii PPO	$419.04

CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION

Facility

$432.00

Service Code	HCPCS 21480
Hospital Charge Code	440214800
Hospital Revenue Code	450
Min. Negotiated Rate	$181.44
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$216.00
Rate for Payer: AlohaCare Medicare	$181.44
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$397.44
Rate for Payer: Devoted Health Medicare	$181.44
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	$181.44
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Humana Medicare	$181.44
Rate for Payer: Kaiser Permanente Commercial	$388.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$181.44
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: Ohana Health Plan Medicaid	$181.44
Rate for Payer: Ohana Health Plan Medicare	$181.44
Rate for Payer: UnitedHealthcare Medicare	$181.44
Rate for Payer: University Health Alliance Commercial	$314.88

CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL WITHO

Facility

$6,394.00

Service Code	HCPCS 27532
Hospital Charge Code	440275320
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$6,202.18
Rate for Payer: AlohaCare Medicaid	$3,197.00
Rate for Payer: AlohaCare Medicare	$2,685.48
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,882.48
Rate for Payer: Devoted Health Medicare	$2,685.48
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	$2,685.48
Rate for Payer: Hawaii Western Management Group Commercial	$6,074.30
Rate for Payer: Health Management Network Commercial	$5,434.90
Rate for Payer: Humana Medicare	$2,685.48
Rate for Payer: Kaiser Permanente Commercial	$5,754.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,685.48
Rate for Payer: MDX Hawaii PPO	$6,202.18
Rate for Payer: Ohana Health Plan Medicaid	$2,685.48
Rate for Payer: Ohana Health Plan Medicare	$2,685.48
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,685.48
Rate for Payer: University Health Alliance Commercial	$4,660.59

CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL WITHO

Facility

$887.00

Service Code	HCPCS 27530
Hospital Charge Code	440275300
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

CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL WITHO

Facility

$6,394.00

Service Code	HCPCS 27532
Hospital Charge Code	440275320
Hospital Revenue Code	450
Min. Negotiated Rate	$5,434.90
Max. Negotiated Rate	$6,202.18
Rate for Payer: Cash Price	$4,156.10
Rate for Payer: Health Management Network Commercial	$5,434.90
Rate for Payer: Kaiser Permanente Commercial	$5,754.60
Rate for Payer: MDX Hawaii PPO	$6,202.18

CLOSED TREATMENT OF TIBIAL FRACTURE PROXIMAL WITHO

Facility

$887.00

Service Code	HCPCS 27530
Hospital Charge Code	440275300
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

CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WI

Facility

$887.00

Service Code	HCPCS 27816
Hospital Charge Code	440278160
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

CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WI

Facility

$887.00

Service Code	HCPCS 27816
Hospital Charge Code	440278160
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

CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WI

Facility

$2,294.00

Service Code	HCPCS 27818
Hospital Charge Code	440278180
Hospital Revenue Code	450
Min. Negotiated Rate	$1,949.90
Max. Negotiated Rate	$2,225.18
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Health Management Network Commercial	$1,949.90
Rate for Payer: Kaiser Permanente Commercial	$2,064.60
Rate for Payer: MDX Hawaii PPO	$2,225.18

CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE WI

Facility

$2,294.00

Service Code	HCPCS 27818
Hospital Charge Code	440278180
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,147.00
Rate for Payer: AlohaCare Medicare	$963.48
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Cash Price	$1,491.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,110.48
Rate for Payer: Devoted Health Medicare	$963.48
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	$963.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,179.30
Rate for Payer: Health Management Network Commercial	$1,949.90
Rate for Payer: Humana Medicare	$963.48
Rate for Payer: Kaiser Permanente Commercial	$2,064.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$963.48
Rate for Payer: MDX Hawaii PPO	$2,225.18
Rate for Payer: Ohana Health Plan Medicaid	$963.48
Rate for Payer: Ohana Health Plan Medicare	$963.48
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$963.48
Rate for Payer: University Health Alliance Commercial	$5,160.40

CLOSED TREATMENT OF ULNAR FRACTURE PROXIMAL END WI

Facility

$554.00

Service Code	HCPCS 24670
Hospital Charge Code	440246700
Hospital Revenue Code	450
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$232.68
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$509.68
Rate for Payer: Devoted Health Medicare	$232.68
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	$232.68
Rate for Payer: Hawaii Western Management Group Commercial	$526.30
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$232.68
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$232.68
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$232.68
Rate for Payer: Ohana Health Plan Medicare	$232.68
Rate for Payer: UnitedHealthcare Medicare	$232.68
Rate for Payer: University Health Alliance Commercial	$403.81

CLOSED TREATMENT OF ULNAR FRACTURE PROXIMAL END WI

Facility

$554.00

Service Code	HCPCS 24670
Hospital Charge Code	440246700
Hospital Revenue Code	450
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

CLOSED TREATMENT OF ULNAR FRACTURE PROXIMAL END WI

Facility

$887.00

Service Code	HCPCS 24675
Hospital Charge Code	440246750
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

CLOSED TREATMENT OF ULNAR FRACTURE PROXIMAL END WI

Facility

$887.00

Service Code	HCPCS 24675
Hospital Charge Code	440246750
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

CLOSED TREATMENT SESAMOID FRACTURE CHARGE

Facility

$554.00

Service Code	HCPCS 28530
Hospital Charge Code	440285300
Hospital Revenue Code	450
Min. Negotiated Rate	$470.90
Max. Negotiated Rate	$537.38
Rate for Payer: Cash Price	$360.10
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: MDX Hawaii PPO	$537.38

CLOSED TREATMENT SESAMOID FRACTURE CHARGE

Facility

$554.00

Service Code	HCPCS 28530
Hospital Charge Code	440285300
Hospital Revenue Code	450
Min. Negotiated Rate	$232.68
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$277.00
Rate for Payer: AlohaCare Medicare	$232.68
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Cash Price	$360.10
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$509.68
Rate for Payer: Devoted Health Medicare	$232.68
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	$232.68
Rate for Payer: Hawaii Western Management Group Commercial	$526.30
Rate for Payer: Health Management Network Commercial	$470.90
Rate for Payer: Humana Medicare	$232.68
Rate for Payer: Kaiser Permanente Commercial	$498.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$232.68
Rate for Payer: MDX Hawaii PPO	$537.38
Rate for Payer: Ohana Health Plan Medicaid	$232.68
Rate for Payer: Ohana Health Plan Medicare	$232.68
Rate for Payer: UnitedHealthcare Medicare	$232.68
Rate for Payer: University Health Alliance Commercial	$403.81

CLOSED TREATMENT TARSAL BONE DISLOCATION REQUIRING

Facility

$10,275.00

Service Code	HCPCS 28545
Hospital Charge Code	440285450
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$9,966.75
Rate for Payer: AlohaCare Medicaid	$5,137.50
Rate for Payer: AlohaCare Medicare	$4,315.50
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Cash Price	$6,678.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9,453.00
Rate for Payer: Devoted Health Medicare	$4,315.50
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	$4,315.50
Rate for Payer: Hawaii Western Management Group Commercial	$9,761.25
Rate for Payer: Health Management Network Commercial	$8,733.75
Rate for Payer: Humana Medicare	$4,315.50
Rate for Payer: Kaiser Permanente Commercial	$9,247.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,315.50
Rate for Payer: MDX Hawaii PPO	$9,966.75
Rate for Payer: Ohana Health Plan Medicaid	$4,315.50
Rate for Payer: Ohana Health Plan Medicare	$4,315.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,315.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges