Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

24200-Upper Arm/Elbow Subcutaneous

Facility

$7,249.00

Service Code	HCPCS 24200
Hospital Charge Code	8080141
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$7,031.53
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$3,624.50
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Devoted Health Medicare	$3,986.95
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,624.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,886.55
Rate for Payer: Health Management Network Commercial	$6,161.65
Rate for Payer: Humana Medicare	$3,624.50
Rate for Payer: Kaiser Permanente Commercial	$6,524.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,624.50
Rate for Payer: MDX Hawaii PPO	$7,031.53
Rate for Payer: Ohana Health Plan Medicaid	$3,624.50
Rate for Payer: Ohana Health Plan Medicare	$3,624.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,624.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

24200-Upper Arm/Elbow Subcutaneous

Facility

$7,249.00

Service Code	HCPCS 24200
Hospital Charge Code	8080141
Hospital Revenue Code	450
Min. Negotiated Rate	$6,161.65
Max. Negotiated Rate	$7,031.53
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Health Management Network Commercial	$6,161.65
Rate for Payer: Kaiser Permanente Commercial	$6,524.10
Rate for Payer: MDX Hawaii PPO	$7,031.53

24505 Closed treatment of humeral shaft fracture; with manipulation, w/wo skeletal traction

Professional

Both

$2,238.00

Service Code	HCPCS 24505
Hospital Charge Code	8037731
Hospital Revenue Code	975
Min. Negotiated Rate	$286.00
Max. Negotiated Rate	$1,902.30
Rate for Payer: AlohaCare Medicaid	$487.76
Rate for Payer: AlohaCare Medicare	$492.26
Rate for Payer: Cash Price	$1,454.70
Rate for Payer: Cash Price	$1,454.70
Rate for Payer: Devoted Health Medicare	$541.49
Rate for Payer: Hawaii Medical Service Association ABD	$487.76
Rate for Payer: Hawaii Medical Service Association Medicare	$492.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$487.76
Rate for Payer: Hawaii Western Management Group Commercial	$286.00
Rate for Payer: Health Management Network Commercial	$1,902.30
Rate for Payer: Kaiser Permanente Commercial	$541.49
Rate for Payer: Kaiser Permanente Medicaid	$541.49
Rate for Payer: Kaiser Permanente Medicare	$541.49
Rate for Payer: Ohana Health Plan Medicaid	$487.76
Rate for Payer: Ohana Health Plan Medicare	$492.26
Rate for Payer: UnitedHealthcare Medicaid	$487.76
Rate for Payer: UnitedHealthcare Medicare	$492.26
Rate for Payer: University Health Alliance Commercial	$628.56

24505-Humeral Shaft w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 24505
Hospital Charge Code	8080105
Hospital Revenue Code	450
Min. Negotiated Rate	$6,259.40
Max. Negotiated Rate	$7,143.08
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Health Management Network Commercial	$6,259.40
Rate for Payer: Kaiser Permanente Commercial	$6,627.60
Rate for Payer: MDX Hawaii PPO	$7,143.08

24505-Humeral Shaft w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 24505
Hospital Charge Code	8080105
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$7,143.08
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$3,682.00
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Devoted Health Medicare	$4,050.20
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,682.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,995.80
Rate for Payer: Health Management Network Commercial	$6,259.40
Rate for Payer: Humana Medicare	$3,682.00
Rate for Payer: Kaiser Permanente Commercial	$6,627.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,682.00
Rate for Payer: MDX Hawaii PPO	$7,143.08
Rate for Payer: Ohana Health Plan Medicaid	$3,682.00
Rate for Payer: Ohana Health Plan Medicare	$3,682.00
Rate for Payer: UnitedHealthcare Medicare	$3,682.00
Rate for Payer: University Health Alliance Commercial	$5,367.62

24577-Humeral Condylar w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 24577
Hospital Charge Code	8080107
Hospital Revenue Code	450
Min. Negotiated Rate	$6,077.50
Max. Negotiated Rate	$6,935.50
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Health Management Network Commercial	$6,077.50
Rate for Payer: Kaiser Permanente Commercial	$6,435.00
Rate for Payer: MDX Hawaii PPO	$6,935.50

24577-Humeral Condylar w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 24577
Hospital Charge Code	8080107
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$6,935.50
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$3,575.00
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Devoted Health Medicare	$3,932.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,575.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,792.50
Rate for Payer: Health Management Network Commercial	$6,077.50
Rate for Payer: Humana Medicare	$3,575.00
Rate for Payer: Kaiser Permanente Commercial	$6,435.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,575.00
Rate for Payer: MDX Hawaii PPO	$6,935.50
Rate for Payer: Ohana Health Plan Medicaid	$3,575.00
Rate for Payer: Ohana Health Plan Medicare	$3,575.00
Rate for Payer: UnitedHealthcare Medicare	$3,575.00
Rate for Payer: University Health Alliance Commercial	$5,211.64

24600-Elbow w/o Anesthesia

Facility

$848.00

Service Code	HCPCS 24600
Hospital Charge Code	8080087
Hospital Revenue Code	450
Min. Negotiated Rate	$720.80
Max. Negotiated Rate	$822.56
Rate for Payer: Cash Price	$551.20
Rate for Payer: Health Management Network Commercial	$720.80
Rate for Payer: Kaiser Permanente Commercial	$763.20
Rate for Payer: MDX Hawaii PPO	$822.56

24600-Elbow w/o Anesthesia

Facility

$848.00

Service Code	HCPCS 24600
Hospital Charge Code	8080087
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,389.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$424.00
Rate for Payer: Cash Price	$551.20
Rate for Payer: Cash Price	$551.20
Rate for Payer: Cash Price	$551.20
Rate for Payer: Devoted Health Medicare	$466.40
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$424.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$805.60
Rate for Payer: Health Management Network Commercial	$720.80
Rate for Payer: Humana Medicare	$424.00
Rate for Payer: Kaiser Permanente Commercial	$763.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$424.00
Rate for Payer: MDX Hawaii PPO	$822.56
Rate for Payer: Ohana Health Plan Medicaid	$424.00
Rate for Payer: Ohana Health Plan Medicare	$424.00
Rate for Payer: UnitedHealthcare Medicare	$424.00
Rate for Payer: University Health Alliance Commercial	$618.11

24605-Elbow w/ Anesthesia

Facility

$7,364.00

Service Code	HCPCS 24605
Hospital Charge Code	8080089
Hospital Revenue Code	450
Min. Negotiated Rate	$6,259.40
Max. Negotiated Rate	$7,143.08
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Health Management Network Commercial	$6,259.40
Rate for Payer: Kaiser Permanente Commercial	$6,627.60
Rate for Payer: MDX Hawaii PPO	$7,143.08

24605-Elbow w/ Anesthesia

Facility

$7,364.00

Service Code	HCPCS 24605
Hospital Charge Code	8080089
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$7,143.08
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$3,682.00
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Devoted Health Medicare	$4,050.20
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,682.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,995.80
Rate for Payer: Health Management Network Commercial	$6,259.40
Rate for Payer: Humana Medicare	$3,682.00
Rate for Payer: Kaiser Permanente Commercial	$6,627.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,682.00
Rate for Payer: MDX Hawaii PPO	$7,143.08
Rate for Payer: Ohana Health Plan Medicaid	$3,682.00
Rate for Payer: Ohana Health Plan Medicare	$3,682.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,682.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

24620-Elbow/ Monteggia w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 24620
Hospital Charge Code	8080109
Hospital Revenue Code	450
Min. Negotiated Rate	$6,259.40
Max. Negotiated Rate	$7,143.08
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Health Management Network Commercial	$6,259.40
Rate for Payer: Kaiser Permanente Commercial	$6,627.60
Rate for Payer: MDX Hawaii PPO	$7,143.08

24620-Elbow/ Monteggia w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 24620
Hospital Charge Code	8080109
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$7,143.08
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$3,682.00
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Cash Price	$4,786.60
Rate for Payer: Devoted Health Medicare	$4,050.20
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,682.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,995.80
Rate for Payer: Health Management Network Commercial	$6,259.40
Rate for Payer: Humana Medicare	$3,682.00
Rate for Payer: Kaiser Permanente Commercial	$6,627.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,682.00
Rate for Payer: MDX Hawaii PPO	$7,143.08
Rate for Payer: Ohana Health Plan Medicaid	$3,682.00
Rate for Payer: Ohana Health Plan Medicare	$3,682.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,682.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ TechFee

Facility

$823.00

Service Code	HCPCS 24640
Hospital Charge Code	8022936
Hospital Revenue Code	450
Min. Negotiated Rate	$699.55
Max. Negotiated Rate	$798.31
Rate for Payer: Cash Price	$534.95
Rate for Payer: Health Management Network Commercial	$699.55
Rate for Payer: Kaiser Permanente Commercial	$740.70
Rate for Payer: MDX Hawaii PPO	$798.31

24640 CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ TechFee

Facility

$823.00

Service Code	HCPCS 24640
Hospital Charge Code	8022936
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,389.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$411.50
Rate for Payer: Cash Price	$534.95
Rate for Payer: Cash Price	$534.95
Rate for Payer: Cash Price	$534.95
Rate for Payer: Devoted Health Medicare	$452.65
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$411.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$781.85
Rate for Payer: Health Management Network Commercial	$699.55
Rate for Payer: Humana Medicare	$411.50
Rate for Payer: Kaiser Permanente Commercial	$740.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$411.50
Rate for Payer: MDX Hawaii PPO	$798.31
Rate for Payer: Ohana Health Plan Medicaid	$411.50
Rate for Payer: Ohana Health Plan Medicare	$411.50
Rate for Payer: UnitedHealthcare Medicare	$411.50
Rate for Payer: University Health Alliance Commercial	$599.88

24640-Nursemaid Elbow

Facility

$848.00

Service Code	HCPCS 24640
Hospital Charge Code	8080091
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,389.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$424.00
Rate for Payer: Cash Price	$551.20
Rate for Payer: Cash Price	$551.20
Rate for Payer: Cash Price	$551.20
Rate for Payer: Devoted Health Medicare	$466.40
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$424.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$805.60
Rate for Payer: Health Management Network Commercial	$720.80
Rate for Payer: Humana Medicare	$424.00
Rate for Payer: Kaiser Permanente Commercial	$763.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$424.00
Rate for Payer: MDX Hawaii PPO	$822.56
Rate for Payer: Ohana Health Plan Medicaid	$424.00
Rate for Payer: Ohana Health Plan Medicare	$424.00
Rate for Payer: UnitedHealthcare Medicare	$424.00
Rate for Payer: University Health Alliance Commercial	$618.11

24640-Nursemaid Elbow

Facility

$848.00

Service Code	HCPCS 24640
Hospital Charge Code	8080091
Hospital Revenue Code	450
Min. Negotiated Rate	$720.80
Max. Negotiated Rate	$822.56
Rate for Payer: Cash Price	$551.20
Rate for Payer: Health Management Network Commercial	$720.80
Rate for Payer: Kaiser Permanente Commercial	$763.20
Rate for Payer: MDX Hawaii PPO	$822.56

24675-Ulna Proximal End w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 24675
Hospital Charge Code	8080111
Hospital Revenue Code	450
Min. Negotiated Rate	$6,077.50
Max. Negotiated Rate	$6,935.50
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Health Management Network Commercial	$6,077.50
Rate for Payer: Kaiser Permanente Commercial	$6,435.00
Rate for Payer: MDX Hawaii PPO	$6,935.50

24675-Ulna Proximal End w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 24675
Hospital Charge Code	8080111
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,935.50
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$3,575.00
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Cash Price	$4,647.50
Rate for Payer: Devoted Health Medicare	$3,932.50
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,575.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,792.50
Rate for Payer: Health Management Network Commercial	$6,077.50
Rate for Payer: Humana Medicare	$3,575.00
Rate for Payer: Kaiser Permanente Commercial	$6,435.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,575.00
Rate for Payer: MDX Hawaii PPO	$6,935.50
Rate for Payer: Ohana Health Plan Medicaid	$3,575.00
Rate for Payer: Ohana Health Plan Medicare	$3,575.00
Rate for Payer: UnitedHealthcare Medicare	$3,575.00
Rate for Payer: University Health Alliance Commercial	$5,211.64

2.4MM 2H L-PLATE, TI, LEFT, 5H

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	12969393
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

2.4MM 2H L-PLATE, TI, LEFT, 5H

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	12969393
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

2.4MM 2H L-PLATE, TI, RIGHT, 5H

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	12969390
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

2.4MM 2H L-PLATE, TI, RIGHT, 5H

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	12969390
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

2.4MM DISTAL RADIUS STYLOID PLATE, TI, 5H

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	12969394
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

2.4MM DISTAL RADIUS STYLOID PLATE, TI, 5H

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Charge Code	12969394
Hospital Revenue Code	278
Min. Negotiated Rate	$1,410.00
Max. Negotiated Rate	$2,735.40
Rate for Payer: AlohaCare Medicaid	$1,410.00
Rate for Payer: AlohaCare Medicare	$1,410.00
Rate for Payer: Cash Price	$1,833.00
Rate for Payer: Devoted Health Medicare	$1,551.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Humana Medicare	$1,410.00
Rate for Payer: Kaiser Permanente Commercial	$2,538.00
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: Kaiser Permanente Medicare	$1,410.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: Ohana Health Plan Medicaid	$1,410.00
Rate for Payer: Ohana Health Plan Medicare	$1,410.00
Rate for Payer: UnitedHealthcare Medicare	$1,410.00
Rate for Payer: University Health Alliance Commercial	$1,579.20

Know your out-of-pocket cost for care.

All Charges