Kau Hospital

All Charges

Charge

Type

Setting

Price

HC INJECT NERV BLCK,AXILLARY NERV

Facility

$3,469.00

Service Code	HCPCS 64417
Hospital Charge Code	3616441701
Hospital Revenue Code	450
Min. Negotiated Rate	$2,948.65
Max. Negotiated Rate	$3,364.93
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: MDX Hawaii PPO	$3,364.93

HC INJECT NERV BLCK,AXILLARY NERV

Facility

$3,469.00

Service Code	HCPCS 64417
Hospital Charge Code	3616441701
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,364.93
Rate for Payer: AlohaCare Medicaid	$1,734.50
Rate for Payer: AlohaCare Medicare	$1,075.39
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Devoted Health Medicare	$1,179.46
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,295.55
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Humana Medicare	$1,075.39
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,075.39
Rate for Payer: MDX Hawaii PPO	$3,364.93
Rate for Payer: Ohana Health Plan Medicaid	$1,075.39
Rate for Payer: Ohana Health Plan Medicare	$1,075.39
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,075.39
Rate for Payer: University Health Alliance Commercial	$2,528.55

HC INJECT NERV BLCK,ILIOINGU/ILIOHYP

Facility

$2,699.00

Service Code	HCPCS 64425
Hospital Charge Code	3616442501
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,618.03
Rate for Payer: AlohaCare Medicaid	$1,349.50
Rate for Payer: AlohaCare Medicare	$836.69
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Devoted Health Medicare	$917.66
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$836.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,564.05
Rate for Payer: Health Management Network Commercial	$2,294.15
Rate for Payer: Humana Medicare	$836.69
Rate for Payer: Kaiser Permanente Commercial	$2,429.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$836.69
Rate for Payer: MDX Hawaii PPO	$2,618.03
Rate for Payer: Ohana Health Plan Medicaid	$836.69
Rate for Payer: Ohana Health Plan Medicare	$836.69
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.69
Rate for Payer: University Health Alliance Commercial	$1,967.30

HC INJECT NERV BLCK,ILIOINGU/ILIOHYP

Facility

$2,699.00

Service Code	HCPCS 64425
Hospital Charge Code	3616442501
Hospital Revenue Code	450
Min. Negotiated Rate	$2,294.15
Max. Negotiated Rate	$2,618.03
Rate for Payer: Cash Price	$1,619.40
Rate for Payer: Health Management Network Commercial	$2,294.15
Rate for Payer: Kaiser Permanente Commercial	$2,429.10
Rate for Payer: MDX Hawaii PPO	$2,618.03

HC INJECT NERV BLCK,INTERCOSTAL,ONE

Facility

$2,756.00

Service Code	HCPCS 64420
Hospital Charge Code	3616442001
Hospital Revenue Code	450
Min. Negotiated Rate	$2,342.60
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Kaiser Permanente Commercial	$2,480.40
Rate for Payer: MDX Hawaii PPO	$2,673.32

HC INJECT NERV BLCK,INTERCOSTAL,ONE

Facility

$2,756.00

Service Code	HCPCS 64420
Hospital Charge Code	3616442001
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,673.32
Rate for Payer: AlohaCare Medicaid	$1,378.00
Rate for Payer: AlohaCare Medicare	$854.36
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Devoted Health Medicare	$937.04
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$854.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Humana Medicare	$854.36
Rate for Payer: Kaiser Permanente Commercial	$2,480.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$854.36
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: Ohana Health Plan Medicaid	$854.36
Rate for Payer: Ohana Health Plan Medicare	$854.36
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$854.36
Rate for Payer: University Health Alliance Commercial	$2,008.85

HC INJECT NERV BLCK,OTHR PERIPH NERV

Facility

$2,756.00

Service Code	HCPCS 64450
Hospital Charge Code	7616445001
Hospital Revenue Code	761
Min. Negotiated Rate	$2,342.60
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Kaiser Permanente Commercial	$2,480.40
Rate for Payer: MDX Hawaii PPO	$2,673.32

HC INJECT NERV BLCK,OTHR PERIPH NERV

Facility

$2,756.00

Service Code	HCPCS 64450
Hospital Charge Code	7616445001
Hospital Revenue Code	761
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,378.00
Rate for Payer: AlohaCare Medicare	$854.36
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Devoted Health Medicare	$937.04
Rate for Payer: Hawaii Medical Service Association Commercial	$901.46
Rate for Payer: Hawaii Medical Service Association Medicare	$854.36
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Humana Medicare	$854.36
Rate for Payer: Kaiser Permanente Commercial	$2,480.40
Rate for Payer: Kaiser Permanente Medicaid	$1,405.56
Rate for Payer: Kaiser Permanente Medicare	$854.36
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: Ohana Health Plan Medicaid	$854.36
Rate for Payer: Ohana Health Plan Medicare	$854.36
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$854.36
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT NERV BLCK,PUDENDAL

Facility

$3,469.00

Service Code	HCPCS 64430
Hospital Charge Code	3616443001
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,734.50
Rate for Payer: AlohaCare Medicare	$1,075.39
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Devoted Health Medicare	$1,179.46
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,295.55
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Humana Medicare	$1,075.39
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,075.39
Rate for Payer: MDX Hawaii PPO	$3,364.93
Rate for Payer: Ohana Health Plan Medicaid	$1,075.39
Rate for Payer: Ohana Health Plan Medicare	$1,075.39
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,075.39
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT NERV BLCK,PUDENDAL

Facility

$3,469.00

Service Code	HCPCS 64430
Hospital Charge Code	3616443001
Hospital Revenue Code	450
Min. Negotiated Rate	$2,948.65
Max. Negotiated Rate	$3,364.93
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: MDX Hawaii PPO	$3,364.93

HC INJECT NERV BLCK,SUPRASCAP N.

Facility

$2,756.00

Service Code	HCPCS 64418
Hospital Charge Code	3616441801
Hospital Revenue Code	450
Min. Negotiated Rate	$2,342.60
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Kaiser Permanente Commercial	$2,480.40
Rate for Payer: MDX Hawaii PPO	$2,673.32

HC INJECT NERV BLCK,SUPRASCAP N.

Facility

$2,756.00

Service Code	HCPCS 64418
Hospital Charge Code	3616441801
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,378.00
Rate for Payer: AlohaCare Medicare	$854.36
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Devoted Health Medicare	$937.04
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$854.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,618.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Humana Medicare	$854.36
Rate for Payer: Kaiser Permanente Commercial	$2,480.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$854.36
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: Ohana Health Plan Medicaid	$854.36
Rate for Payer: Ohana Health Plan Medicare	$854.36
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$854.36
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT NERV BLCK,TRIGEMINAL

Facility

$1,175.00

Service Code	HCPCS 64400
Hospital Charge Code	4506440001
Hospital Revenue Code	450
Min. Negotiated Rate	$998.75
Max. Negotiated Rate	$1,139.75
Rate for Payer: Cash Price	$705.00
Rate for Payer: Health Management Network Commercial	$998.75
Rate for Payer: Kaiser Permanente Commercial	$1,057.50
Rate for Payer: MDX Hawaii PPO	$1,139.75

HC INJECT NERV BLCK,TRIGEMINAL

Facility

$1,175.00

Service Code	HCPCS 64400
Hospital Charge Code	4506440001
Hospital Revenue Code	450
Min. Negotiated Rate	$364.25
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$587.50
Rate for Payer: AlohaCare Medicare	$364.25
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Devoted Health Medicare	$399.50
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$364.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,116.25
Rate for Payer: Health Management Network Commercial	$998.75
Rate for Payer: Humana Medicare	$364.25
Rate for Payer: Kaiser Permanente Commercial	$1,057.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$364.25
Rate for Payer: MDX Hawaii PPO	$1,139.75
Rate for Payer: Ohana Health Plan Medicaid	$364.25
Rate for Payer: Ohana Health Plan Medicare	$364.25
Rate for Payer: UnitedHealthcare Medicare	$364.25
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJECT TRIGGER POINT, 1 OR 2

Facility

$1,175.00

Service Code	HCPCS 20552
Hospital Charge Code	7612055201
Hospital Revenue Code	761
Min. Negotiated Rate	$998.75
Max. Negotiated Rate	$1,139.75
Rate for Payer: Cash Price	$705.00
Rate for Payer: Health Management Network Commercial	$998.75
Rate for Payer: Kaiser Permanente Commercial	$1,057.50
Rate for Payer: MDX Hawaii PPO	$1,139.75

HC INJECT TRIGGER POINT, 1 OR 2

Facility

$1,175.00

Service Code	HCPCS 20552
Hospital Charge Code	7612055201
Hospital Revenue Code	761
Min. Negotiated Rate	$35.03
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$587.50
Rate for Payer: AlohaCare Medicare	$364.25
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Cash Price	$705.00
Rate for Payer: Devoted Health Medicare	$399.50
Rate for Payer: Hawaii Medical Service Association Commercial	$392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$364.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,116.25
Rate for Payer: Health Management Network Commercial	$998.75
Rate for Payer: Humana Medicare	$364.25
Rate for Payer: Kaiser Permanente Commercial	$1,057.50
Rate for Payer: Kaiser Permanente Medicaid	$599.25
Rate for Payer: Kaiser Permanente Medicare	$364.25
Rate for Payer: MDX Hawaii PPO	$1,139.75
Rate for Payer: Ohana Health Plan Medicaid	$364.25
Rate for Payer: Ohana Health Plan Medicare	$364.25
Rate for Payer: UnitedHealthcare Medicaid	$35.03
Rate for Payer: UnitedHealthcare Medicare	$364.25
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INJ INTRA-ARTERIAL

Facility

$838.00

Service Code	HCPCS 96373
Hospital Charge Code	4509637301
Hospital Revenue Code	450
Min. Negotiated Rate	$712.30
Max. Negotiated Rate	$812.86
Rate for Payer: Cash Price	$502.80
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: Kaiser Permanente Commercial	$754.20
Rate for Payer: MDX Hawaii PPO	$812.86

HC INJ INTRA-ARTERIAL

Facility

$838.00

Service Code	HCPCS 96373
Hospital Charge Code	4509637301
Hospital Revenue Code	450
Min. Negotiated Rate	$259.78
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$419.00
Rate for Payer: AlohaCare Medicare	$259.78
Rate for Payer: Cash Price	$502.80
Rate for Payer: Cash Price	$502.80
Rate for Payer: Devoted Health Medicare	$284.92
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$259.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$796.10
Rate for Payer: Health Management Network Commercial	$712.30
Rate for Payer: Humana Medicare	$259.78
Rate for Payer: Kaiser Permanente Commercial	$754.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$259.78
Rate for Payer: MDX Hawaii PPO	$812.86
Rate for Payer: Ohana Health Plan Medicaid	$259.78
Rate for Payer: Ohana Health Plan Medicare	$259.78
Rate for Payer: UnitedHealthcare Medicare	$259.78
Rate for Payer: University Health Alliance Commercial	$610.82

HC INJX, DX OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JT W/ US GUIDANCE, CERV OR THOR; SINGLE LVL

Facility

$3,469.00

Service Code	HCPCS 0213T
Hospital Charge Code	4500213701
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,364.93
Rate for Payer: AlohaCare Medicaid	$1,734.50
Rate for Payer: AlohaCare Medicare	$1,075.39
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Devoted Health Medicare	$1,179.46
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,295.55
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Humana Medicare	$1,075.39
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,075.39
Rate for Payer: MDX Hawaii PPO	$3,364.93
Rate for Payer: Ohana Health Plan Medicaid	$1,075.39
Rate for Payer: Ohana Health Plan Medicare	$1,075.39
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,075.39
Rate for Payer: University Health Alliance Commercial	$2,528.55

HC INJX, DX OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JT W/ US GUIDANCE, CERV OR THOR; SINGLE LVL

Facility

$3,469.00

Service Code	HCPCS 0213T
Hospital Charge Code	4500213701
Hospital Revenue Code	450
Min. Negotiated Rate	$2,948.65
Max. Negotiated Rate	$3,364.93
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: MDX Hawaii PPO	$3,364.93

HC INJX, DX OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JT W/ US GUIDANCE, LUMB OR SACRAL; SINGLE LEVEL

Facility

$3,469.00

Service Code	HCPCS 0216T
Hospital Charge Code	4500216701
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,364.93
Rate for Payer: AlohaCare Medicaid	$1,734.50
Rate for Payer: AlohaCare Medicare	$1,075.39
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Devoted Health Medicare	$1,179.46
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,295.55
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Humana Medicare	$1,075.39
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,075.39
Rate for Payer: MDX Hawaii PPO	$3,364.93
Rate for Payer: Ohana Health Plan Medicaid	$1,075.39
Rate for Payer: Ohana Health Plan Medicare	$1,075.39
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,075.39
Rate for Payer: University Health Alliance Commercial	$2,528.55

HC INJX, DX OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET JT W/ US GUIDANCE, LUMB OR SACRAL; SINGLE LEVEL

Facility

$3,469.00

Service Code	HCPCS 0216T
Hospital Charge Code	4500216701
Hospital Revenue Code	450
Min. Negotiated Rate	$2,948.65
Max. Negotiated Rate	$3,364.93
Rate for Payer: Cash Price	$2,081.40
Rate for Payer: Health Management Network Commercial	$2,948.65
Rate for Payer: Kaiser Permanente Commercial	$3,122.10
Rate for Payer: MDX Hawaii PPO	$3,364.93

HC INSERT EMERGENCY ENDOTRACH AIRWAY

Facility

$924.00

Service Code	HCPCS 31500
Hospital Charge Code	7613150001
Hospital Revenue Code	761
Min. Negotiated Rate	$785.40
Max. Negotiated Rate	$896.28
Rate for Payer: Cash Price	$554.40
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: Kaiser Permanente Commercial	$831.60
Rate for Payer: MDX Hawaii PPO	$896.28

HC INSERT EMERGENCY ENDOTRACH AIRWAY

Facility

$924.00

Service Code	HCPCS 31500
Hospital Charge Code	7613150001
Hospital Revenue Code	761
Min. Negotiated Rate	$93.64
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$462.00
Rate for Payer: AlohaCare Medicare	$286.44
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cash Price	$554.40
Rate for Payer: Devoted Health Medicare	$314.16
Rate for Payer: Hawaii Medical Service Association Commercial	$302.48
Rate for Payer: Hawaii Medical Service Association Medicare	$286.44
Rate for Payer: Hawaii Western Management Group Commercial	$877.80
Rate for Payer: Health Management Network Commercial	$785.40
Rate for Payer: Humana Medicare	$286.44
Rate for Payer: Kaiser Permanente Commercial	$831.60
Rate for Payer: Kaiser Permanente Medicaid	$471.24
Rate for Payer: Kaiser Permanente Medicare	$286.44
Rate for Payer: MDX Hawaii PPO	$896.28
Rate for Payer: Ohana Health Plan Medicaid	$286.44
Rate for Payer: Ohana Health Plan Medicare	$286.44
Rate for Payer: UnitedHealthcare Medicaid	$93.64
Rate for Payer: UnitedHealthcare Medicare	$286.44
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL

Facility

$12,643.00

Service Code	HCPCS 20650
Hospital Charge Code	4502065001
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$12,263.71
Rate for Payer: AlohaCare Medicaid	$6,321.50
Rate for Payer: AlohaCare Medicare	$3,919.33
Rate for Payer: Cash Price	$7,585.80
Rate for Payer: Cash Price	$7,585.80
Rate for Payer: Devoted Health Medicare	$4,298.62
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,919.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$12,010.85
Rate for Payer: Health Management Network Commercial	$10,746.55
Rate for Payer: Humana Medicare	$3,919.33
Rate for Payer: Kaiser Permanente Commercial	$11,378.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,919.33
Rate for Payer: MDX Hawaii PPO	$12,263.71
Rate for Payer: Ohana Health Plan Medicaid	$3,919.33
Rate for Payer: Ohana Health Plan Medicare	$3,919.33
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,919.33
Rate for Payer: University Health Alliance Commercial	$6,743.44

Know your out-of-pocket cost for care.

All Charges