Kau Hospital

All Charges

Charge

Type

Setting

Price

PR REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF

Professional

Both

$1,304.00

Service Code	HCPCS 36833
Min. Negotiated Rate	$626.60
Max. Negotiated Rate	$1,108.40
Rate for Payer: AlohaCare Medicaid	$764.46
Rate for Payer: AlohaCare Medicare	$705.40
Rate for Payer: Cash Price	$782.40
Rate for Payer: Cash Price	$782.40
Rate for Payer: Devoted Health Medicare	$775.94
Rate for Payer: Hawaii Medical Service Association Medicare	$705.40
Rate for Payer: Hawaii Western Management Group Commercial	$626.60
Rate for Payer: Health Management Network Commercial	$1,108.40
Rate for Payer: Kaiser Permanente Commercial	$846.48
Rate for Payer: Kaiser Permanente Medicaid	$846.48
Rate for Payer: Kaiser Permanente Medicare	$846.48
Rate for Payer: Ohana Health Plan Medicaid	$764.46
Rate for Payer: Ohana Health Plan Medicare	$705.40
Rate for Payer: UnitedHealthcare Medicaid	$764.46
Rate for Payer: UnitedHealthcare Medicare	$705.40

PR REVJ/RPLCMT HPGLSL NERVE NSTIM RA PG&RESPIR SNR

Professional

Both

$1,502.00

Service Code	HCPCS 64583
Min. Negotiated Rate	$744.17
Max. Negotiated Rate	$1,276.70
Rate for Payer: AlohaCare Medicaid	$878.72
Rate for Payer: AlohaCare Medicare	$744.17
Rate for Payer: Cash Price	$901.20
Rate for Payer: Cash Price	$901.20
Rate for Payer: Devoted Health Medicare	$818.59
Rate for Payer: Hawaii Medical Service Association Medicare	$744.17
Rate for Payer: Health Management Network Commercial	$1,276.70
Rate for Payer: Kaiser Permanente Commercial	$893.00
Rate for Payer: Kaiser Permanente Medicaid	$893.00
Rate for Payer: Kaiser Permanente Medicare	$893.00
Rate for Payer: Ohana Health Plan Medicaid	$878.72
Rate for Payer: Ohana Health Plan Medicare	$744.17
Rate for Payer: UnitedHealthcare Medicaid	$878.72
Rate for Payer: UnitedHealthcare Medicare	$744.17

PR REVJ TOTAL KNEE ARTHRP W/WO ALGRFT 1 COMPONENT

Professional

Both

$2,449.00

Service Code	HCPCS 27486
Min. Negotiated Rate	$1,215.50
Max. Negotiated Rate	$2,081.65
Rate for Payer: AlohaCare Medicaid	$1,426.06
Rate for Payer: AlohaCare Medicare	$1,274.28
Rate for Payer: Cash Price	$1,469.40
Rate for Payer: Cash Price	$1,469.40
Rate for Payer: Devoted Health Medicare	$1,401.71
Rate for Payer: Hawaii Medical Service Association Medicare	$1,274.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,215.50
Rate for Payer: Health Management Network Commercial	$2,081.65
Rate for Payer: Kaiser Permanente Commercial	$1,529.14
Rate for Payer: Kaiser Permanente Medicaid	$1,529.14
Rate for Payer: Kaiser Permanente Medicare	$1,529.14
Rate for Payer: Ohana Health Plan Medicaid	$1,426.06
Rate for Payer: Ohana Health Plan Medicare	$1,274.28
Rate for Payer: UnitedHealthcare Medicaid	$1,426.06
Rate for Payer: UnitedHealthcare Medicare	$1,274.28

PR REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT

Professional

Both

$3,276.00

Service Code	HCPCS 27134
Min. Negotiated Rate	$1,675.58
Max. Negotiated Rate	$2,784.60
Rate for Payer: AlohaCare Medicaid	$1,909.31
Rate for Payer: AlohaCare Medicare	$1,675.58
Rate for Payer: Cash Price	$1,965.60
Rate for Payer: Cash Price	$1,965.60
Rate for Payer: Devoted Health Medicare	$1,843.14
Rate for Payer: Hawaii Medical Service Association Medicare	$1,675.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,779.96
Rate for Payer: Health Management Network Commercial	$2,784.60
Rate for Payer: Kaiser Permanente Commercial	$2,010.70
Rate for Payer: Kaiser Permanente Medicaid	$2,010.70
Rate for Payer: Kaiser Permanente Medicare	$2,010.70
Rate for Payer: Ohana Health Plan Medicaid	$1,909.31
Rate for Payer: Ohana Health Plan Medicare	$1,675.58
Rate for Payer: UnitedHealthcare Medicaid	$1,909.31
Rate for Payer: UnitedHealthcare Medicare	$1,675.58

PR REVJ TRANSVNS INTRHPTC PORTOSYSTEMIC SHNT (TIPS)

Professional

Both

$10,674.26

Service Code	HCPCS 37183
Min. Negotiated Rate	$315.71
Max. Negotiated Rate	$9,073.12
Rate for Payer: AlohaCare Medicaid	$360.94
Rate for Payer: AlohaCare Medicare	$315.71
Rate for Payer: Cash Price	$6,404.56
Rate for Payer: Cash Price	$6,404.56
Rate for Payer: Devoted Health Medicare	$347.28
Rate for Payer: Hawaii Medical Service Association ABD	$360.94
Rate for Payer: Hawaii Medical Service Association Commercial	$570.45
Rate for Payer: Hawaii Medical Service Association Medicare	$315.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$360.94
Rate for Payer: Health Management Network Commercial	$9,073.12
Rate for Payer: Kaiser Permanente Commercial	$378.85
Rate for Payer: Kaiser Permanente Medicaid	$378.85
Rate for Payer: Kaiser Permanente Medicare	$378.85
Rate for Payer: Ohana Health Plan Medicaid	$360.94
Rate for Payer: Ohana Health Plan Medicare	$315.71
Rate for Payer: UnitedHealthcare Medicaid	$360.94
Rate for Payer: UnitedHealthcare Medicare	$315.71
Rate for Payer: University Health Alliance Commercial	$492.98

PR REVJ UR-CUTAN ANAST RPR FSCAL DFCT & HERNIA

Professional

Both

$1,221.00

Service Code	HCPCS 50728
Min. Negotiated Rate	$573.56
Max. Negotiated Rate	$1,037.85
Rate for Payer: AlohaCare Medicaid	$712.09
Rate for Payer: AlohaCare Medicare	$641.71
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cash Price	$732.60
Rate for Payer: Devoted Health Medicare	$705.88
Rate for Payer: Hawaii Medical Service Association Medicare	$641.71
Rate for Payer: Hawaii Western Management Group Commercial	$573.56
Rate for Payer: Health Management Network Commercial	$1,037.85
Rate for Payer: Kaiser Permanente Commercial	$770.05
Rate for Payer: Kaiser Permanente Medicaid	$770.05
Rate for Payer: Kaiser Permanente Medicare	$770.05
Rate for Payer: Ohana Health Plan Medicaid	$712.09
Rate for Payer: Ohana Health Plan Medicare	$641.71
Rate for Payer: UnitedHealthcare Medicaid	$712.09
Rate for Payer: UnitedHealthcare Medicare	$641.71

PR REVJ URINARY-CUTANEOUS ANASTAMOSIS

Professional

Both

$899.00

Service Code	HCPCS 50727
Min. Negotiated Rate	$396.50
Max. Negotiated Rate	$764.15
Rate for Payer: AlohaCare Medicaid	$526.41
Rate for Payer: AlohaCare Medicare	$480.90
Rate for Payer: Cash Price	$539.40
Rate for Payer: Cash Price	$539.40
Rate for Payer: Devoted Health Medicare	$528.99
Rate for Payer: Hawaii Medical Service Association Medicare	$480.90
Rate for Payer: Hawaii Western Management Group Commercial	$396.50
Rate for Payer: Health Management Network Commercial	$764.15
Rate for Payer: Kaiser Permanente Commercial	$577.08
Rate for Payer: Kaiser Permanente Medicaid	$577.08
Rate for Payer: Kaiser Permanente Medicare	$577.08
Rate for Payer: Ohana Health Plan Medicaid	$526.41
Rate for Payer: Ohana Health Plan Medicare	$480.90
Rate for Payer: UnitedHealthcare Medicaid	$526.41
Rate for Payer: UnitedHealthcare Medicare	$480.90

PR REV/RMV PRPH SAC/GSTRC NPG/RCV DTCH CONN ELTR RA

Professional

Both

$644.95

Service Code	HCPCS 64595
Min. Negotiated Rate	$86.84
Max. Negotiated Rate	$548.21
Rate for Payer: AlohaCare Medicaid	$233.77
Rate for Payer: AlohaCare Medicare	$211.31
Rate for Payer: Cash Price	$386.97
Rate for Payer: Cash Price	$386.97
Rate for Payer: Devoted Health Medicare	$232.44
Rate for Payer: Hawaii Medical Service Association ABD	$233.77
Rate for Payer: Hawaii Medical Service Association Commercial	$220.01
Rate for Payer: Hawaii Medical Service Association Medicare	$211.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$233.77
Rate for Payer: Hawaii Western Management Group Commercial	$86.84
Rate for Payer: Health Management Network Commercial	$548.21
Rate for Payer: Kaiser Permanente Commercial	$253.57
Rate for Payer: Kaiser Permanente Medicaid	$253.57
Rate for Payer: Kaiser Permanente Medicare	$253.57
Rate for Payer: Ohana Health Plan Medicaid	$233.77
Rate for Payer: Ohana Health Plan Medicare	$211.31
Rate for Payer: UnitedHealthcare Medicaid	$233.77
Rate for Payer: UnitedHealthcare Medicare	$211.31
Rate for Payer: University Health Alliance Commercial	$171.83

PR REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL

Professional

Both

$22,773.00

Service Code	HCPCS 37265
Min. Negotiated Rate	$453.36
Max. Negotiated Rate	$19,357.05
Rate for Payer: AlohaCare Medicare	$453.36
Rate for Payer: Cash Price	$13,663.80
Rate for Payer: Cash Price	$13,663.80
Rate for Payer: Devoted Health Medicare	$498.70
Rate for Payer: Hawaii Medical Service Association Medicare	$453.36
Rate for Payer: Health Management Network Commercial	$19,357.05
Rate for Payer: Kaiser Permanente Commercial	$544.03
Rate for Payer: Kaiser Permanente Medicaid	$544.03
Rate for Payer: Kaiser Permanente Medicare	$544.03
Rate for Payer: Ohana Health Plan Medicare	$453.36
Rate for Payer: UnitedHealthcare Medicare	$453.36

PR REVSC EVASC FPVT ANGIOP UNI SF LES 1ST VSL

Professional

Both

$10,682.00

Service Code	HCPCS 37263
Min. Negotiated Rate	$335.26
Max. Negotiated Rate	$9,079.70
Rate for Payer: AlohaCare Medicare	$335.26
Rate for Payer: Cash Price	$6,409.20
Rate for Payer: Cash Price	$6,409.20
Rate for Payer: Devoted Health Medicare	$368.79
Rate for Payer: Hawaii Medical Service Association Medicare	$335.26
Rate for Payer: Health Management Network Commercial	$9,079.70
Rate for Payer: Kaiser Permanente Commercial	$402.31
Rate for Payer: Kaiser Permanente Medicaid	$402.31
Rate for Payer: Kaiser Permanente Medicare	$402.31
Rate for Payer: Ohana Health Plan Medicare	$335.26
Rate for Payer: UnitedHealthcare Medicare	$335.26

PR REVSC EVASC FPVT ANGIOP UNI SF LES EA ADDL VSL

Professional

Both

$4,298.00

Service Code	HCPCS 37264
Min. Negotiated Rate	$128.17
Max. Negotiated Rate	$3,653.30
Rate for Payer: AlohaCare Medicare	$128.17
Rate for Payer: Cash Price	$2,578.80
Rate for Payer: Cash Price	$2,578.80
Rate for Payer: Devoted Health Medicare	$140.99
Rate for Payer: Hawaii Medical Service Association Medicare	$128.17
Rate for Payer: Health Management Network Commercial	$3,653.30
Rate for Payer: Kaiser Permanente Commercial	$153.80
Rate for Payer: Kaiser Permanente Medicaid	$153.80
Rate for Payer: Kaiser Permanente Medicare	$153.80
Rate for Payer: Ohana Health Plan Medicare	$128.17
Rate for Payer: UnitedHealthcare Medicare	$128.17

PR REVSC EVASC FPVT ATHRC UNI CPLX LES 1ST VSL

Professional

Both

$30,478.00

Service Code	HCPCS 37273
Min. Negotiated Rate	$544.93
Max. Negotiated Rate	$25,906.30
Rate for Payer: AlohaCare Medicare	$544.93
Rate for Payer: Cash Price	$18,286.80
Rate for Payer: Cash Price	$18,286.80
Rate for Payer: Devoted Health Medicare	$599.42
Rate for Payer: Hawaii Medical Service Association Medicare	$544.93
Rate for Payer: Health Management Network Commercial	$25,906.30
Rate for Payer: Kaiser Permanente Commercial	$653.92
Rate for Payer: Kaiser Permanente Medicaid	$653.92
Rate for Payer: Kaiser Permanente Medicare	$653.92
Rate for Payer: Ohana Health Plan Medicare	$544.93
Rate for Payer: UnitedHealthcare Medicare	$544.93

PR REVSC EVASC FPVT ATHRC UNI SF LES 1ST VSL

Professional

Both

$20,293.00

Service Code	HCPCS 37271
Min. Negotiated Rate	$389.42
Max. Negotiated Rate	$17,249.05
Rate for Payer: AlohaCare Medicare	$389.42
Rate for Payer: Cash Price	$12,175.80
Rate for Payer: Cash Price	$12,175.80
Rate for Payer: Devoted Health Medicare	$428.36
Rate for Payer: Hawaii Medical Service Association Medicare	$389.42
Rate for Payer: Health Management Network Commercial	$17,249.05
Rate for Payer: Kaiser Permanente Commercial	$467.30
Rate for Payer: Kaiser Permanente Medicaid	$467.30
Rate for Payer: Kaiser Permanente Medicare	$467.30
Rate for Payer: Ohana Health Plan Medicare	$389.42
Rate for Payer: UnitedHealthcare Medicare	$389.42

PR REVSC EVASC FPVT ST ATHRC UNI CPLX LES 1ST VSL

Professional

Both

$30,478.00

Service Code	HCPCS 37277
Min. Negotiated Rate	$642.91
Max. Negotiated Rate	$25,906.30
Rate for Payer: AlohaCare Medicare	$642.91
Rate for Payer: Cash Price	$18,286.80
Rate for Payer: Cash Price	$18,286.80
Rate for Payer: Devoted Health Medicare	$707.20
Rate for Payer: Hawaii Medical Service Association Medicare	$642.91
Rate for Payer: Health Management Network Commercial	$25,906.30
Rate for Payer: Kaiser Permanente Commercial	$771.49
Rate for Payer: Kaiser Permanente Medicaid	$771.49
Rate for Payer: Kaiser Permanente Medicare	$771.49
Rate for Payer: Ohana Health Plan Medicare	$642.91
Rate for Payer: UnitedHealthcare Medicare	$642.91

PR REVSC EVASC FPVT ST ATHRC UNI SF LES 1ST VSL

Professional

Both

$20,293.00

Service Code	HCPCS 37275
Min. Negotiated Rate	$472.92
Max. Negotiated Rate	$17,249.05
Rate for Payer: AlohaCare Medicare	$472.92
Rate for Payer: Cash Price	$12,175.80
Rate for Payer: Cash Price	$12,175.80
Rate for Payer: Devoted Health Medicare	$520.21
Rate for Payer: Hawaii Medical Service Association Medicare	$472.92
Rate for Payer: Health Management Network Commercial	$17,249.05
Rate for Payer: Kaiser Permanente Commercial	$567.50
Rate for Payer: Kaiser Permanente Medicaid	$567.50
Rate for Payer: Kaiser Permanente Medicare	$567.50
Rate for Payer: Ohana Health Plan Medicare	$472.92
Rate for Payer: UnitedHealthcare Medicare	$472.92

PR REVSC EVASC FPVT ST PLMT UNI CPLX LES 1ST VSL

Professional

Both

$26,151.00

Service Code	HCPCS 37269
Min. Negotiated Rate	$633.85
Max. Negotiated Rate	$22,228.35
Rate for Payer: AlohaCare Medicare	$633.85
Rate for Payer: Cash Price	$15,690.60
Rate for Payer: Cash Price	$15,690.60
Rate for Payer: Devoted Health Medicare	$697.24
Rate for Payer: Hawaii Medical Service Association Medicare	$633.85
Rate for Payer: Health Management Network Commercial	$22,228.35
Rate for Payer: Kaiser Permanente Commercial	$760.62
Rate for Payer: Kaiser Permanente Medicaid	$760.62
Rate for Payer: Kaiser Permanente Medicare	$760.62
Rate for Payer: Ohana Health Plan Medicare	$633.85
Rate for Payer: UnitedHealthcare Medicare	$633.85

PR REVSC EVASC FPVT ST PLMT UNI SF LES 1ST VSL

Professional

Both

$20,898.00

Service Code	HCPCS 37267
Min. Negotiated Rate	$377.49
Max. Negotiated Rate	$17,763.30
Rate for Payer: AlohaCare Medicare	$377.49
Rate for Payer: Cash Price	$12,538.80
Rate for Payer: Cash Price	$12,538.80
Rate for Payer: Devoted Health Medicare	$415.24
Rate for Payer: Hawaii Medical Service Association Medicare	$377.49
Rate for Payer: Health Management Network Commercial	$17,763.30
Rate for Payer: Kaiser Permanente Commercial	$452.99
Rate for Payer: Kaiser Permanente Medicaid	$452.99
Rate for Payer: Kaiser Permanente Medicare	$452.99
Rate for Payer: Ohana Health Plan Medicare	$377.49
Rate for Payer: UnitedHealthcare Medicare	$377.49

PR REVSC EVASC IMVT ANGIOP UNI SF LES 1ST VSL

Professional

Both

$6,213.00

Service Code	HCPCS 37296
Min. Negotiated Rate	$471.80
Max. Negotiated Rate	$5,281.05
Rate for Payer: AlohaCare Medicare	$471.80
Rate for Payer: Cash Price	$3,727.80
Rate for Payer: Cash Price	$3,727.80
Rate for Payer: Devoted Health Medicare	$518.98
Rate for Payer: Hawaii Medical Service Association Medicare	$471.80
Rate for Payer: Health Management Network Commercial	$5,281.05
Rate for Payer: Kaiser Permanente Commercial	$566.16
Rate for Payer: Kaiser Permanente Medicaid	$566.16
Rate for Payer: Kaiser Permanente Medicare	$566.16
Rate for Payer: Ohana Health Plan Medicare	$471.80
Rate for Payer: UnitedHealthcare Medicare	$471.80

PR REVSC EVASC IVT ANGIOP UNI CPLX LES 1ST VSL

Professional

Both

$6,955.00

Service Code	HCPCS 37256
Min. Negotiated Rate	$463.43
Max. Negotiated Rate	$5,911.75
Rate for Payer: AlohaCare Medicare	$463.43
Rate for Payer: Cash Price	$4,173.00
Rate for Payer: Cash Price	$4,173.00
Rate for Payer: Devoted Health Medicare	$509.77
Rate for Payer: Hawaii Medical Service Association Medicare	$463.43
Rate for Payer: Health Management Network Commercial	$5,911.75
Rate for Payer: Kaiser Permanente Commercial	$556.12
Rate for Payer: Kaiser Permanente Medicaid	$556.12
Rate for Payer: Kaiser Permanente Medicare	$556.12
Rate for Payer: Ohana Health Plan Medicare	$463.43
Rate for Payer: UnitedHealthcare Medicare	$463.43

PR REVSC EVASC IVT ANGIOP UNI CPLX LES EA ADDL VSL

Professional

Both

$1,092.00

Service Code	HCPCS 37257
Min. Negotiated Rate	$165.19
Max. Negotiated Rate	$928.20
Rate for Payer: AlohaCare Medicare	$165.19
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cash Price	$655.20
Rate for Payer: Devoted Health Medicare	$181.71
Rate for Payer: Hawaii Medical Service Association Medicare	$165.19
Rate for Payer: Health Management Network Commercial	$928.20
Rate for Payer: Kaiser Permanente Commercial	$198.23
Rate for Payer: Kaiser Permanente Medicaid	$198.23
Rate for Payer: Kaiser Permanente Medicare	$198.23
Rate for Payer: Ohana Health Plan Medicare	$165.19
Rate for Payer: UnitedHealthcare Medicare	$165.19

PR REVSC EVASC IVT ANGIOP UNI SF LES 1ST VSL

Professional

Both

$4,012.00

Service Code	HCPCS 37254
Min. Negotiated Rate	$316.39
Max. Negotiated Rate	$3,410.20
Rate for Payer: AlohaCare Medicare	$316.39
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Cash Price	$2,407.20
Rate for Payer: Devoted Health Medicare	$348.03
Rate for Payer: Hawaii Medical Service Association Medicare	$316.39
Rate for Payer: Health Management Network Commercial	$3,410.20
Rate for Payer: Kaiser Permanente Commercial	$379.67
Rate for Payer: Kaiser Permanente Medicaid	$379.67
Rate for Payer: Kaiser Permanente Medicare	$379.67
Rate for Payer: Ohana Health Plan Medicare	$316.39
Rate for Payer: UnitedHealthcare Medicare	$316.39

PR REVSC EVASC IVT ANGIOP UNI SF LES EA ADDL VSL

Professional

Both

$4,671.00

Service Code	HCPCS 37255
Min. Negotiated Rate	$127.61
Max. Negotiated Rate	$3,970.35
Rate for Payer: AlohaCare Medicare	$127.61
Rate for Payer: Cash Price	$2,802.60
Rate for Payer: Cash Price	$2,802.60
Rate for Payer: Devoted Health Medicare	$140.37
Rate for Payer: Hawaii Medical Service Association Medicare	$127.61
Rate for Payer: Health Management Network Commercial	$3,970.35
Rate for Payer: Kaiser Permanente Commercial	$153.13
Rate for Payer: Kaiser Permanente Medicaid	$153.13
Rate for Payer: Kaiser Permanente Medicare	$153.13
Rate for Payer: Ohana Health Plan Medicare	$127.61
Rate for Payer: UnitedHealthcare Medicare	$127.61

PR REVSC EVASC IVT ST PLMT UNI CPLX LES 1ST VSL

Professional

Both

$10,691.00

Service Code	HCPCS 37260
Min. Negotiated Rate	$544.92
Max. Negotiated Rate	$9,087.35
Rate for Payer: AlohaCare Medicare	$544.92
Rate for Payer: Cash Price	$6,414.60
Rate for Payer: Cash Price	$6,414.60
Rate for Payer: Devoted Health Medicare	$599.41
Rate for Payer: Hawaii Medical Service Association Medicare	$544.92
Rate for Payer: Health Management Network Commercial	$9,087.35
Rate for Payer: Kaiser Permanente Commercial	$653.90
Rate for Payer: Kaiser Permanente Medicaid	$653.90
Rate for Payer: Kaiser Permanente Medicare	$653.90
Rate for Payer: Ohana Health Plan Medicare	$544.92
Rate for Payer: UnitedHealthcare Medicare	$544.92

PR REVSC EVASC IVT ST PLMT UNI CPLX LES EA ADDL VSL

Professional

Both

$13,433.00

Service Code	HCPCS 37261
Min. Negotiated Rate	$180.30
Max. Negotiated Rate	$11,418.05
Rate for Payer: AlohaCare Medicare	$180.30
Rate for Payer: Cash Price	$8,059.80
Rate for Payer: Cash Price	$8,059.80
Rate for Payer: Devoted Health Medicare	$198.33
Rate for Payer: Hawaii Medical Service Association Medicare	$180.30
Rate for Payer: Health Management Network Commercial	$11,418.05
Rate for Payer: Kaiser Permanente Commercial	$216.36
Rate for Payer: Kaiser Permanente Medicaid	$216.36
Rate for Payer: Kaiser Permanente Medicare	$216.36
Rate for Payer: Ohana Health Plan Medicare	$180.30
Rate for Payer: UnitedHealthcare Medicare	$180.30

PR REVSC EVASC IVT ST PLMT UNI SF LES 1ST VSL

Professional

Both

$6,955.00

Service Code	HCPCS 37258
Min. Negotiated Rate	$377.11
Max. Negotiated Rate	$5,911.75
Rate for Payer: AlohaCare Medicare	$377.11
Rate for Payer: Cash Price	$4,173.00
Rate for Payer: Cash Price	$4,173.00
Rate for Payer: Devoted Health Medicare	$414.82
Rate for Payer: Hawaii Medical Service Association Medicare	$377.11
Rate for Payer: Health Management Network Commercial	$5,911.75
Rate for Payer: Kaiser Permanente Commercial	$452.53
Rate for Payer: Kaiser Permanente Medicaid	$452.53
Rate for Payer: Kaiser Permanente Medicare	$452.53
Rate for Payer: Ohana Health Plan Medicare	$377.11
Rate for Payer: UnitedHealthcare Medicare	$377.11

Know your out-of-pocket cost for care.

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