Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

25500-Radial Shaft w/o Manipulation

Facility

$1,434.00

Service Code	HCPCS 25500
Hospital Charge Code	8080113
Hospital Revenue Code	450
Min. Negotiated Rate	$1,218.90
Max. Negotiated Rate	$1,390.98
Rate for Payer: Cash Price	$932.10
Rate for Payer: Health Management Network Commercial	$1,218.90
Rate for Payer: Kaiser Permanente Commercial	$1,290.60
Rate for Payer: MDX Hawaii PPO	$1,390.98

25500-Radial Shaft w/o Manipulation

Facility

$1,434.00

Service Code	HCPCS 25500
Hospital Charge Code	8080113
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$717.00
Rate for Payer: Cash Price	$932.10
Rate for Payer: Cash Price	$932.10
Rate for Payer: Cash Price	$932.10
Rate for Payer: Devoted Health Medicare	$788.70
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	$717.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.30
Rate for Payer: Health Management Network Commercial	$1,218.90
Rate for Payer: Humana Medicare	$717.00
Rate for Payer: Kaiser Permanente Commercial	$1,290.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$717.00
Rate for Payer: MDX Hawaii PPO	$1,390.98
Rate for Payer: Ohana Health Plan Medicaid	$717.00
Rate for Payer: Ohana Health Plan Medicare	$717.00
Rate for Payer: UnitedHealthcare Medicare	$717.00
Rate for Payer: University Health Alliance Commercial	$1,045.24

25505-Radial Shaft w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 25505
Hospital Charge Code	8080115
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

25505-Radial Shaft w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 25505
Hospital Charge Code	8080115
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
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	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,682.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,682.00
Rate for Payer: University Health Alliance Commercial	$5,367.62

25535-Ulnar Shaft w/ Manipulation

Facility

$1,441.00

Service Code	HCPCS 25535
Hospital Charge Code	8080117
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	$720.50
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$792.55
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	$720.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,368.95
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Humana Medicare	$720.50
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$720.50
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$720.50
Rate for Payer: Ohana Health Plan Medicare	$720.50
Rate for Payer: UnitedHealthcare Medicare	$720.50
Rate for Payer: University Health Alliance Commercial	$1,050.34

25535-Ulnar Shaft w/ Manipulation

Facility

$1,441.00

Service Code	HCPCS 25535
Hospital Charge Code	8080117
Hospital Revenue Code	450
Min. Negotiated Rate	$1,224.85
Max. Negotiated Rate	$1,397.77
Rate for Payer: Cash Price	$936.65
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77

25560-Radial & Ulnar Shaft w/o Manipulation

Facility

$1,434.00

Service Code	HCPCS 25560
Hospital Charge Code	8080119
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	$717.00
Rate for Payer: Cash Price	$932.10
Rate for Payer: Cash Price	$932.10
Rate for Payer: Cash Price	$932.10
Rate for Payer: Devoted Health Medicare	$788.70
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	$717.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.30
Rate for Payer: Health Management Network Commercial	$1,218.90
Rate for Payer: Humana Medicare	$717.00
Rate for Payer: Kaiser Permanente Commercial	$1,290.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$717.00
Rate for Payer: MDX Hawaii PPO	$1,390.98
Rate for Payer: Ohana Health Plan Medicaid	$717.00
Rate for Payer: Ohana Health Plan Medicare	$717.00
Rate for Payer: UnitedHealthcare Medicare	$717.00
Rate for Payer: University Health Alliance Commercial	$1,045.24

25560-Radial & Ulnar Shaft w/o Manipulation

Facility

$1,434.00

Service Code	HCPCS 25560
Hospital Charge Code	8080119
Hospital Revenue Code	450
Min. Negotiated Rate	$1,218.90
Max. Negotiated Rate	$1,390.98
Rate for Payer: Cash Price	$932.10
Rate for Payer: Health Management Network Commercial	$1,218.90
Rate for Payer: Kaiser Permanente Commercial	$1,290.60
Rate for Payer: MDX Hawaii PPO	$1,390.98

25565-Radial&Ulnar Shaft w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 25565
Hospital Charge Code	8080121
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

25565-Radial&Ulnar Shaft w/ Manipulation

Facility

$7,364.00

Service Code	HCPCS 25565
Hospital Charge Code	8080121
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$10,679.55
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	$10,679.55

25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ TechFee

Facility

$843.00

Service Code	HCPCS 25600
Hospital Charge Code	8022989
Hospital Revenue Code	450
Min. Negotiated Rate	$421.50
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$421.50
Rate for Payer: Cash Price	$547.95
Rate for Payer: Cash Price	$547.95
Rate for Payer: Cash Price	$547.95
Rate for Payer: Devoted Health Medicare	$463.65
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	$421.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$800.85
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Humana Medicare	$421.50
Rate for Payer: Kaiser Permanente Commercial	$758.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$421.50
Rate for Payer: MDX Hawaii PPO	$817.71
Rate for Payer: Ohana Health Plan Medicaid	$421.50
Rate for Payer: Ohana Health Plan Medicare	$421.50
Rate for Payer: UnitedHealthcare Medicare	$421.50
Rate for Payer: University Health Alliance Commercial	$20,300.00

25600 CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ TechFee

Facility

$843.00

Service Code	HCPCS 25600
Hospital Charge Code	8022989
Hospital Revenue Code	450
Min. Negotiated Rate	$716.55
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$547.95
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Kaiser Permanente Commercial	$758.70
Rate for Payer: MDX Hawaii PPO	$817.71

25600-Distal Radial w/o Manipulation

Facility

$773.00

Service Code	HCPCS 25600
Hospital Charge Code	8080123
Hospital Revenue Code	450
Min. Negotiated Rate	$386.50
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$386.50
Rate for Payer: Cash Price	$502.45
Rate for Payer: Cash Price	$502.45
Rate for Payer: Cash Price	$502.45
Rate for Payer: Devoted Health Medicare	$425.15
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	$386.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$734.35
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Humana Medicare	$386.50
Rate for Payer: Kaiser Permanente Commercial	$695.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$386.50
Rate for Payer: MDX Hawaii PPO	$749.81
Rate for Payer: Ohana Health Plan Medicaid	$386.50
Rate for Payer: Ohana Health Plan Medicare	$386.50
Rate for Payer: UnitedHealthcare Medicare	$386.50
Rate for Payer: University Health Alliance Commercial	$20,300.00

25600-Distal Radial w/o Manipulation

Facility

$773.00

Service Code	HCPCS 25600
Hospital Charge Code	8080123
Hospital Revenue Code	450
Min. Negotiated Rate	$657.05
Max. Negotiated Rate	$749.81
Rate for Payer: Cash Price	$502.45
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Kaiser Permanente Commercial	$695.70
Rate for Payer: MDX Hawaii PPO	$749.81

25605 CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF TechFee

Facility

$3,830.00

Service Code	HCPCS 25605
Hospital Charge Code	8022990
Hospital Revenue Code	450
Min. Negotiated Rate	$3,255.50
Max. Negotiated Rate	$3,715.10
Rate for Payer: Cash Price	$2,489.50
Rate for Payer: Health Management Network Commercial	$3,255.50
Rate for Payer: Kaiser Permanente Commercial	$3,447.00
Rate for Payer: MDX Hawaii PPO	$3,715.10

25605 CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF TechFee

Facility

$3,830.00

Service Code	HCPCS 25605
Hospital Charge Code	8022990
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,915.00
Rate for Payer: Cash Price	$2,489.50
Rate for Payer: Cash Price	$2,489.50
Rate for Payer: Cash Price	$2,489.50
Rate for Payer: Devoted Health Medicare	$2,106.50
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,915.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,638.50
Rate for Payer: Health Management Network Commercial	$3,255.50
Rate for Payer: Humana Medicare	$1,915.00
Rate for Payer: Kaiser Permanente Commercial	$3,447.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,915.00
Rate for Payer: MDX Hawaii PPO	$3,715.10
Rate for Payer: Ohana Health Plan Medicaid	$1,915.00
Rate for Payer: Ohana Health Plan Medicare	$1,915.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,915.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

25605-Distal Radial w/ Manipulation

Facility

$3,544.00

Service Code	HCPCS 25605
Hospital Charge Code	8080125
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,772.00
Rate for Payer: Cash Price	$2,303.60
Rate for Payer: Cash Price	$2,303.60
Rate for Payer: Cash Price	$2,303.60
Rate for Payer: Devoted Health Medicare	$1,949.20
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,772.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,366.80
Rate for Payer: Health Management Network Commercial	$3,012.40
Rate for Payer: Humana Medicare	$1,772.00
Rate for Payer: Kaiser Permanente Commercial	$3,189.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,772.00
Rate for Payer: MDX Hawaii PPO	$3,437.68
Rate for Payer: Ohana Health Plan Medicaid	$1,772.00
Rate for Payer: Ohana Health Plan Medicare	$1,772.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,772.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

25605-Distal Radial w/ Manipulation

Facility

$3,544.00

Service Code	HCPCS 25605
Hospital Charge Code	8080125
Hospital Revenue Code	450
Min. Negotiated Rate	$3,012.40
Max. Negotiated Rate	$3,437.68
Rate for Payer: Cash Price	$2,303.60
Rate for Payer: Health Management Network Commercial	$3,012.40
Rate for Payer: Kaiser Permanente Commercial	$3,189.60
Rate for Payer: MDX Hawaii PPO	$3,437.68

25622 TREAT WRIST BONE FRACTURE TechFee

Facility

$843.00

Service Code	HCPCS 25622
Hospital Charge Code	8022995
Hospital Revenue Code	450
Min. Negotiated Rate	$716.55
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$547.95
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Kaiser Permanente Commercial	$758.70
Rate for Payer: MDX Hawaii PPO	$817.71

25622 TREAT WRIST BONE FRACTURE TechFee

Facility

$843.00

Service Code	HCPCS 25622
Hospital Charge Code	8022995
Hospital Revenue Code	450
Min. Negotiated Rate	$421.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$421.50
Rate for Payer: Cash Price	$547.95
Rate for Payer: Cash Price	$547.95
Rate for Payer: Cash Price	$547.95
Rate for Payer: Devoted Health Medicare	$463.65
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	$421.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$800.85
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Humana Medicare	$421.50
Rate for Payer: Kaiser Permanente Commercial	$758.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$421.50
Rate for Payer: MDX Hawaii PPO	$817.71
Rate for Payer: Ohana Health Plan Medicaid	$421.50
Rate for Payer: Ohana Health Plan Medicare	$421.50
Rate for Payer: UnitedHealthcare Medicare	$421.50
Rate for Payer: University Health Alliance Commercial	$614.46

25660-Radiocarpal/Intercarpal Dislocation w/ Manipulation

Facility

$1,434.00

Service Code	HCPCS 25660
Hospital Charge Code	8080093
Hospital Revenue Code	450
Min. Negotiated Rate	$1,218.90
Max. Negotiated Rate	$1,390.98
Rate for Payer: Cash Price	$932.10
Rate for Payer: Health Management Network Commercial	$1,218.90
Rate for Payer: Kaiser Permanente Commercial	$1,290.60
Rate for Payer: MDX Hawaii PPO	$1,390.98

25660-Radiocarpal/Intercarpal Dislocation w/ Manipulation

Facility

$1,434.00

Service Code	HCPCS 25660
Hospital Charge Code	8080093
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	$717.00
Rate for Payer: Cash Price	$932.10
Rate for Payer: Cash Price	$932.10
Rate for Payer: Cash Price	$932.10
Rate for Payer: Devoted Health Medicare	$788.70
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	$717.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.30
Rate for Payer: Health Management Network Commercial	$1,218.90
Rate for Payer: Humana Medicare	$717.00
Rate for Payer: Kaiser Permanente Commercial	$1,290.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$717.00
Rate for Payer: MDX Hawaii PPO	$1,390.98
Rate for Payer: Ohana Health Plan Medicaid	$717.00
Rate for Payer: Ohana Health Plan Medicare	$717.00
Rate for Payer: UnitedHealthcare Medicare	$717.00
Rate for Payer: University Health Alliance Commercial	$1,045.24

25675 Closed treatment of distal radioulnar dislocation with manipulation

Facility

$1,338.00

Service Code	HCPCS 25675
Hospital Charge Code	8037867
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	$669.00
Rate for Payer: Cash Price	$869.70
Rate for Payer: Cash Price	$869.70
Rate for Payer: Cash Price	$869.70
Rate for Payer: Devoted Health Medicare	$735.90
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	$669.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,271.10
Rate for Payer: Health Management Network Commercial	$1,137.30
Rate for Payer: Humana Medicare	$669.00
Rate for Payer: Kaiser Permanente Commercial	$1,204.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$669.00
Rate for Payer: MDX Hawaii PPO	$1,297.86
Rate for Payer: Ohana Health Plan Medicaid	$669.00
Rate for Payer: Ohana Health Plan Medicare	$669.00
Rate for Payer: UnitedHealthcare Medicare	$669.00
Rate for Payer: University Health Alliance Commercial	$975.27

25675 Closed treatment of distal radioulnar dislocation with manipulation

Facility

$1,338.00

Service Code	HCPCS 25675
Hospital Charge Code	8037867
Hospital Revenue Code	450
Min. Negotiated Rate	$1,137.30
Max. Negotiated Rate	$1,297.86
Rate for Payer: Cash Price	$869.70
Rate for Payer: Health Management Network Commercial	$1,137.30
Rate for Payer: Kaiser Permanente Commercial	$1,204.20
Rate for Payer: MDX Hawaii PPO	$1,297.86

25675-Clsd Treat Distal Radioulnar Disloc w/ Manip

Facility

$1,388.00

Service Code	HCPCS 25675
Hospital Charge Code	8957889
Hospital Revenue Code	450
Min. Negotiated Rate	$1,179.80
Max. Negotiated Rate	$1,346.36
Rate for Payer: Cash Price	$902.20
Rate for Payer: Health Management Network Commercial	$1,179.80
Rate for Payer: Kaiser Permanente Commercial	$1,249.20
Rate for Payer: MDX Hawaii PPO	$1,346.36

Know your out-of-pocket cost for care.

All Charges