Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

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

CLOSED TX FINGER DISLOC Charge

Facility

$554.00

Service Code	HCPCS 26670
Hospital Charge Code	440266700
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 TX FINGER DISLOC Charge

Facility

$554.00

Service Code	HCPCS 26670
Hospital Charge Code	440266700
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 TX METATARSAL FRACTURE W/O MANIPULATION

Professional

Both

$709.00

Service Code	HCPCS 28470
Hospital Revenue Code	361
Min. Negotiated Rate	$184.86
Max. Negotiated Rate	$602.65
Rate for Payer: AlohaCare Medicaid	$228.27
Rate for Payer: AlohaCare Medicare	$222.89
Rate for Payer: Cash Price	$460.85
Rate for Payer: Cash Price	$460.85
Rate for Payer: Devoted Health Medicare	$222.89
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$228.27
Rate for Payer: Hawaii Medical Service Association Medicare	$222.89
Rate for Payer: Hawaii Western Management Group Commercial	$184.86
Rate for Payer: Health Management Network Commercial	$602.65
Rate for Payer: Kaiser Permanente Commercial	$267.47
Rate for Payer: Kaiser Permanente Medicaid	$267.47
Rate for Payer: Kaiser Permanente Medicare	$267.47
Rate for Payer: Ohana Health Plan Medicaid	$228.27
Rate for Payer: Ohana Health Plan Medicare	$222.89
Rate for Payer: UnitedHealthcare Medicaid	$228.27
Rate for Payer: UnitedHealthcare Medicare	$222.89
Rate for Payer: University Health Alliance Commercial	$320.00

CLOSED TX SUPRACONDYLAR HUMERAL FRACTURE W/MANIPUL

Facility

$887.00

Service Code	HCPCS 24535
Hospital Charge Code	440245350
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 TX SUPRACONDYLAR HUMERAL FRACTURE W/MANIPUL

Facility

$887.00

Service Code	HCPCS 24535
Hospital Charge Code	440245350
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

CLOSE TX BIMALLOR ANKLE W/O MA Charge

Facility

$887.00

Service Code	HCPCS 27808
Hospital Charge Code	440278080
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

CLOSE TX BIMALLOR ANKLE W/O MA Charge

Facility

$887.00

Service Code	HCPCS 27808
Hospital Charge Code	440278080
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

CLOSURE OF LACERATION VESTIBULE OF MOUTH 2.5 CM OR

Facility

$1,335.00

Service Code	HCPCS 40830
Hospital Charge Code	440408300
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$667.50
Rate for Payer: AlohaCare Medicare	$560.70
Rate for Payer: Cash Price	$867.75
Rate for Payer: Cash Price	$867.75
Rate for Payer: Cash Price	$867.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,228.20
Rate for Payer: Devoted Health Medicare	$560.70
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	$560.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,268.25
Rate for Payer: Health Management Network Commercial	$1,134.75
Rate for Payer: Humana Medicare	$560.70
Rate for Payer: Kaiser Permanente Commercial	$1,201.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$560.70
Rate for Payer: MDX Hawaii PPO	$1,294.95
Rate for Payer: Ohana Health Plan Medicaid	$560.70
Rate for Payer: Ohana Health Plan Medicare	$560.70
Rate for Payer: UnitedHealthcare Medicare	$560.70
Rate for Payer: University Health Alliance Commercial	$973.08

CLOSURE OF LACERATION VESTIBULE OF MOUTH 2.5 CM OR

Facility

$1,335.00

Service Code	HCPCS 40830
Hospital Charge Code	440408300
Hospital Revenue Code	450
Min. Negotiated Rate	$1,134.75
Max. Negotiated Rate	$1,294.95
Rate for Payer: Cash Price	$867.75
Rate for Payer: Health Management Network Commercial	$1,134.75
Rate for Payer: Kaiser Permanente Commercial	$1,201.50
Rate for Payer: MDX Hawaii PPO	$1,294.95

clotrimazole 10 mg Loz [KMC]

Facility

$6.43

Service Code	NDC 00054414622
Hospital Revenue Code	250
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$6.24
Rate for Payer: Cash Price	$4.18
Rate for Payer: Health Management Network Commercial	$5.47
Rate for Payer: Kaiser Permanente Commercial	$5.79
Rate for Payer: MDX Hawaii PPO	$6.24

clotrimazole 10 mg Loz [KMC]

Facility

$6.43

Service Code	NDC 00054414622
Hospital Revenue Code	250
Min. Negotiated Rate	$2.70
Max. Negotiated Rate	$6.24
Rate for Payer: AlohaCare Medicaid	$3.21
Rate for Payer: AlohaCare Medicare	$2.70
Rate for Payer: Cash Price	$4.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.92
Rate for Payer: Devoted Health Medicare	$2.70
Rate for Payer: Hawaii Medical Service Association Medicare	$2.70
Rate for Payer: Hawaii Western Management Group Commercial	$6.11
Rate for Payer: Health Management Network Commercial	$5.47
Rate for Payer: Humana Medicare	$2.70
Rate for Payer: Kaiser Permanente Commercial	$5.79
Rate for Payer: Kaiser Permanente Medicaid	$3.28
Rate for Payer: Kaiser Permanente Medicare	$2.70
Rate for Payer: MDX Hawaii PPO	$6.24
Rate for Payer: Ohana Health Plan Medicaid	$2.70
Rate for Payer: Ohana Health Plan Medicare	$2.70
Rate for Payer: UnitedHealthcare Medicaid	$3.86
Rate for Payer: UnitedHealthcare Medicare	$2.70
Rate for Payer: University Health Alliance Commercial	$4.69

clotrimazole 1% Cream [KMC]

Facility

$1.15

Service Code	NDC 45802043411
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$1.12
Rate for Payer: AlohaCare Medicaid	$0.58
Rate for Payer: AlohaCare Medicare	$0.48
Rate for Payer: Cash Price	$0.75
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.06
Rate for Payer: Devoted Health Medicare	$0.48
Rate for Payer: Hawaii Medical Service Association Medicare	$0.48
Rate for Payer: Hawaii Western Management Group Commercial	$1.09
Rate for Payer: Health Management Network Commercial	$0.98
Rate for Payer: Humana Medicare	$0.48
Rate for Payer: Kaiser Permanente Commercial	$1.03
Rate for Payer: Kaiser Permanente Medicaid	$0.59
Rate for Payer: Kaiser Permanente Medicare	$0.48
Rate for Payer: MDX Hawaii PPO	$1.12
Rate for Payer: Ohana Health Plan Medicaid	$0.48
Rate for Payer: Ohana Health Plan Medicare	$0.48
Rate for Payer: UnitedHealthcare Medicaid	$0.69
Rate for Payer: UnitedHealthcare Medicare	$0.48
Rate for Payer: University Health Alliance Commercial	$0.84

clotrimazole 1% Cream [KMC]

Facility

$1.15

Service Code	NDC 45802043411
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.75
Rate for Payer: Health Management Network Commercial	$0.98
Rate for Payer: Kaiser Permanente Commercial	$1.03
Rate for Payer: MDX Hawaii PPO	$1.12

clotrimazole topical 1% Soln [KMC]

Facility

$9.96

Service Code	NDC 51672126003
Hospital Revenue Code	250
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$9.66
Rate for Payer: AlohaCare Medicaid	$4.98
Rate for Payer: AlohaCare Medicare	$4.18
Rate for Payer: Cash Price	$6.47
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$9.16
Rate for Payer: Devoted Health Medicare	$4.18
Rate for Payer: Hawaii Medical Service Association Medicare	$4.18
Rate for Payer: Hawaii Western Management Group Commercial	$9.46
Rate for Payer: Health Management Network Commercial	$8.47
Rate for Payer: Humana Medicare	$4.18
Rate for Payer: Kaiser Permanente Commercial	$8.96
Rate for Payer: Kaiser Permanente Medicaid	$5.08
Rate for Payer: Kaiser Permanente Medicare	$4.18
Rate for Payer: MDX Hawaii PPO	$9.66
Rate for Payer: Ohana Health Plan Medicaid	$4.18
Rate for Payer: Ohana Health Plan Medicare	$4.18
Rate for Payer: UnitedHealthcare Medicaid	$5.98
Rate for Payer: UnitedHealthcare Medicare	$4.18
Rate for Payer: University Health Alliance Commercial	$7.26

clotrimazole topical 1% Soln [KMC]

Facility

$9.96

Service Code	NDC 51672126003
Hospital Revenue Code	250
Min. Negotiated Rate	$8.47
Max. Negotiated Rate	$9.66
Rate for Payer: Cash Price	$6.47
Rate for Payer: Health Management Network Commercial	$8.47
Rate for Payer: Kaiser Permanente Commercial	$8.96
Rate for Payer: MDX Hawaii PPO	$9.66

CLSD TX FEMORAL FX D

Facility

$887.00

Service Code	HCPCS 27508
Hospital Charge Code	440275080
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

CLSD TX FEMORAL FX D

Facility

$887.00

Service Code	HCPCS 27508
Hospital Charge Code	440275080
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

CLSD TX FX STERNUM Charge

Facility

$554.00

Service Code	HCPCS 21820
Hospital Charge Code	440218200
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

CLSD TX FX STERNUM Charge

Facility

$554.00

Service Code	HCPCS 21820
Hospital Charge Code	440218200
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

CLSD TX NASAL SEPTAL FX W/WO Charge

Facility

$6,219.00

Service Code	HCPCS 21337
Hospital Charge Code	440213370
Hospital Revenue Code	450
Min. Negotiated Rate	$5,286.15
Max. Negotiated Rate	$6,032.43
Rate for Payer: Cash Price	$4,042.35
Rate for Payer: Health Management Network Commercial	$5,286.15
Rate for Payer: Kaiser Permanente Commercial	$5,597.10
Rate for Payer: MDX Hawaii PPO	$6,032.43

CLSD TX NASAL SEPTAL FX W/WO Charge

Facility

$6,219.00

Service Code	HCPCS 21337
Hospital Charge Code	440213370
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$6,032.43
Rate for Payer: AlohaCare Medicaid	$3,109.50
Rate for Payer: AlohaCare Medicare	$2,611.98
Rate for Payer: Cash Price	$4,042.35
Rate for Payer: Cash Price	$4,042.35
Rate for Payer: Cash Price	$4,042.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,721.48
Rate for Payer: Devoted Health Medicare	$2,611.98
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	$2,611.98
Rate for Payer: Hawaii Western Management Group Commercial	$5,908.05
Rate for Payer: Health Management Network Commercial	$5,286.15
Rate for Payer: Humana Medicare	$2,611.98
Rate for Payer: Kaiser Permanente Commercial	$5,597.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,611.98
Rate for Payer: MDX Hawaii PPO	$6,032.43
Rate for Payer: Ohana Health Plan Medicaid	$2,611.98
Rate for Payer: Ohana Health Plan Medicare	$2,611.98
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,611.98
Rate for Payer: University Health Alliance Commercial	$5,160.40

CLSD TX RAD/IC DISLOC W/MAN Charge

Facility

$887.00

Service Code	HCPCS 25660
Hospital Charge Code	440256600
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

CLSD TX RAD/IC DISLOC W/MAN Charge

Facility

$887.00

Service Code	HCPCS 25660
Hospital Charge Code	440256600
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

CLSD TX STRN/CLAV DISLC W/MAN Charge

Facility

$887.00

Service Code	HCPCS 23525
Hospital Charge Code	440235250
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

Know your out-of-pocket cost for care.

All Charges