Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

27372 REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA TechFee

Facility

$12,492.00

Service Code	HCPCS 27372
Hospital Charge Code	8023117
Hospital Revenue Code	450
Min. Negotiated Rate	$10,618.20
Max. Negotiated Rate	$12,117.24
Rate for Payer: Cash Price	$8,119.80
Rate for Payer: Health Management Network Commercial	$10,618.20
Rate for Payer: Kaiser Permanente Commercial	$11,242.80
Rate for Payer: MDX Hawaii PPO	$12,117.24

27372 REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA TechFee

Facility

$12,492.00

Service Code	HCPCS 27372
Hospital Charge Code	8023117
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$2,177.19
Rate for Payer: AlohaCare Medicare	$6,246.00
Rate for Payer: Cash Price	$8,119.80
Rate for Payer: Cash Price	$8,119.80
Rate for Payer: Devoted Health Medicare	$6,870.60
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	$6,246.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$11,867.40
Rate for Payer: Health Management Network Commercial	$10,618.20
Rate for Payer: Humana Medicare	$6,246.00
Rate for Payer: Kaiser Permanente Commercial	$11,242.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$6,246.00
Rate for Payer: MDX Hawaii PPO	$12,117.24
Rate for Payer: Ohana Health Plan Medicaid	$6,246.00
Rate for Payer: Ohana Health Plan Medicare	$6,246.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,246.00
Rate for Payer: University Health Alliance Commercial	$16,700.00

27500 CLOSED TREAT FEMORAL SHAFT FRACTURE, WITHOUT MANIPULATION TechFee

Facility

$1,081.00

Service Code	HCPCS 27500
Hospital Charge Code	8023137
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	$540.50
Rate for Payer: Cash Price	$702.65
Rate for Payer: Cash Price	$702.65
Rate for Payer: Cash Price	$702.65
Rate for Payer: Devoted Health Medicare	$594.55
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	$540.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,026.95
Rate for Payer: Health Management Network Commercial	$918.85
Rate for Payer: Humana Medicare	$540.50
Rate for Payer: Kaiser Permanente Commercial	$972.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$540.50
Rate for Payer: MDX Hawaii PPO	$1,048.57
Rate for Payer: Ohana Health Plan Medicaid	$540.50
Rate for Payer: Ohana Health Plan Medicare	$540.50
Rate for Payer: UnitedHealthcare Medicare	$540.50
Rate for Payer: University Health Alliance Commercial	$787.94

27500 CLOSED TREAT FEMORAL SHAFT FRACTURE, WITHOUT MANIPULATION TechFee

Facility

$1,081.00

Service Code	HCPCS 27500
Hospital Charge Code	8023137
Hospital Revenue Code	450
Min. Negotiated Rate	$918.85
Max. Negotiated Rate	$1,048.57
Rate for Payer: Cash Price	$702.65
Rate for Payer: Health Management Network Commercial	$918.85
Rate for Payer: Kaiser Permanente Commercial	$972.90
Rate for Payer: MDX Hawaii PPO	$1,048.57

27502-Femoral Shaft w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27502
Hospital Charge Code	8080106
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

27502-Femoral Shaft w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27502
Hospital Charge Code	8080106
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,575.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
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 Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,575.00
Rate for Payer: University Health Alliance Commercial	$5,211.64

27510-Femoral Distal w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27510
Hospital Charge Code	8080108
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

27510-Femoral Distal w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27510
Hospital Charge Code	8080108
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

27550-Knee w/o Anesthesia

Facility

$1,434.00

Service Code	HCPCS 27550
Hospital Charge Code	8080090
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

27550-Knee w/o Anesthesia

Facility

$1,434.00

Service Code	HCPCS 27550
Hospital Charge Code	8080090
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

27552-Knee w/ Anesthesia

Facility

$7,150.00

Service Code	HCPCS 27552
Hospital Charge Code	8080092
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$6,935.50
Rate for Payer: AlohaCare Medicaid	$672.48
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: 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 Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,575.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

27552-Knee w/ Anesthesia

Facility

$7,150.00

Service Code	HCPCS 27552
Hospital Charge Code	8080092
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

27560 CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA TechFee

Facility

$823.00

Service Code	HCPCS 27560
Hospital Charge Code	8023154
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

27560 CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA TechFee

Facility

$823.00

Service Code	HCPCS 27560
Hospital Charge Code	8023154
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

27560-Patellar w/o Anesthesia

Facility

$848.00

Service Code	HCPCS 27560
Hospital Charge Code	8080094
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

27560-Patellar w/o Anesthesia

Facility

$848.00

Service Code	HCPCS 27560
Hospital Charge Code	8080094
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

27616 RADICAL RESECTION OF TUMOR (EG, SARCOMA), SOFT TISSUE OF LEG OR ANKLE AREA; 5 CM OR GR ProFee

Professional

Both

$4,043.00

Service Code	HCPCS 27616
Hospital Charge Code	8018007
Hospital Revenue Code	960
Min. Negotiated Rate	$1,152.11
Max. Negotiated Rate	$3,436.55
Rate for Payer: AlohaCare Medicaid	$1,268.06
Rate for Payer: AlohaCare Medicare	$1,152.11
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Devoted Health Medicare	$1,267.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,152.11
Rate for Payer: Health Management Network Commercial	$3,436.55
Rate for Payer: Kaiser Permanente Commercial	$1,267.32
Rate for Payer: Kaiser Permanente Medicaid	$1,267.32
Rate for Payer: Kaiser Permanente Medicare	$1,267.32
Rate for Payer: Ohana Health Plan Medicaid	$1,268.06
Rate for Payer: Ohana Health Plan Medicare	$1,152.11
Rate for Payer: UnitedHealthcare Medicaid	$1,268.06
Rate for Payer: UnitedHealthcare Medicare	$1,152.11

27750 CLTX TIBIAL SHAFT FX W/O MANIPULATION TechFee

Facility

$843.00

Service Code	HCPCS 27750
Hospital Charge Code	8023193
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	$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	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$421.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
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

27750 CLTX TIBIAL SHAFT FX W/O MANIPULATION TechFee

Facility

$843.00

Service Code	HCPCS 27750
Hospital Charge Code	8023193
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

27752-Tibial Shaft w/ Manipulation

Facility

$3,404.00

Service Code	HCPCS 27752
Hospital Charge Code	8080110
Hospital Revenue Code	450
Min. Negotiated Rate	$2,893.40
Max. Negotiated Rate	$3,301.88
Rate for Payer: Cash Price	$2,212.60
Rate for Payer: Health Management Network Commercial	$2,893.40
Rate for Payer: Kaiser Permanente Commercial	$3,063.60
Rate for Payer: MDX Hawaii PPO	$3,301.88

27752-Tibial Shaft w/ Manipulation

Facility

$3,404.00

Service Code	HCPCS 27752
Hospital Charge Code	8080110
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,702.00
Rate for Payer: Cash Price	$2,212.60
Rate for Payer: Cash Price	$2,212.60
Rate for Payer: Cash Price	$2,212.60
Rate for Payer: Devoted Health Medicare	$1,872.20
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	$1,702.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,233.80
Rate for Payer: Health Management Network Commercial	$2,893.40
Rate for Payer: Humana Medicare	$1,702.00
Rate for Payer: Kaiser Permanente Commercial	$3,063.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,702.00
Rate for Payer: MDX Hawaii PPO	$3,301.88
Rate for Payer: Ohana Health Plan Medicaid	$1,702.00
Rate for Payer: Ohana Health Plan Medicare	$1,702.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,702.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

27762-Medial Malleolus w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27762
Hospital Charge Code	8080112
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

27762-Medial Malleolus w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27762
Hospital Charge Code	8080112
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
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	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,575.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
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 Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,575.00
Rate for Payer: University Health Alliance Commercial	$5,211.64

27768-Posterior Malleolus w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27768
Hospital Charge Code	8080114
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

27768-Posterior Malleolus w/ Manipulation

Facility

$7,150.00

Service Code	HCPCS 27768
Hospital Charge Code	8080114
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

Know your out-of-pocket cost for care.

All Charges