Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

haloperidol 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00378025701
Hospital Charge Code	2500370
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.50
Rate for Payer: Cash Price	$1.95
Rate for Payer: Devoted Health Medicare	$1.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1.50
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.50
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.50
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.50
Rate for Payer: Ohana Health Plan Medicare	$1.50
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.50
Rate for Payer: University Health Alliance Commercial	$2.19

haloperidol 1 mg tablet [HHSC]

Facility

$3.00

Service Code	NDC 00378025701
Hospital Charge Code	2500370
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

haloperidol 5mg/1ml vial [HHSC]

Facility

$44.70

Service Code	HCPCS J1630
Hospital Charge Code	2500372
Hospital Revenue Code	636
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$43.36
Rate for Payer: AlohaCare Medicaid	$22.35
Rate for Payer: AlohaCare Medicaid	$4.00
Rate for Payer: AlohaCare Medicare	$4.00
Rate for Payer: AlohaCare Medicare	$22.35
Rate for Payer: Cash Price	$29.06
Rate for Payer: Cash Price	$29.06
Rate for Payer: Cash Price	$5.21
Rate for Payer: Cash Price	$5.21
Rate for Payer: Devoted Health Medicare	$24.59
Rate for Payer: Devoted Health Medicare	$4.41
Rate for Payer: Hawaii Medical Service Association ABD	$0.84
Rate for Payer: Hawaii Medical Service Association ABD	$0.84
Rate for Payer: Hawaii Medical Service Association Medicare	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$22.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.84
Rate for Payer: Hawaii Western Management Group Commercial	$42.47
Rate for Payer: Hawaii Western Management Group Commercial	$7.61
Rate for Payer: Health Management Network Commercial	$6.81
Rate for Payer: Health Management Network Commercial	$37.99
Rate for Payer: Humana Medicare	$4.00
Rate for Payer: Humana Medicare	$22.35
Rate for Payer: Kaiser Permanente Commercial	$40.23
Rate for Payer: Kaiser Permanente Commercial	$7.21
Rate for Payer: Kaiser Permanente Medicaid	$4.09
Rate for Payer: Kaiser Permanente Medicaid	$22.80
Rate for Payer: Kaiser Permanente Medicare	$22.35
Rate for Payer: Kaiser Permanente Medicare	$4.00
Rate for Payer: MDX Hawaii PPO	$43.36
Rate for Payer: MDX Hawaii PPO	$7.77
Rate for Payer: Ohana Health Plan Medicaid	$4.00
Rate for Payer: Ohana Health Plan Medicaid	$22.35
Rate for Payer: Ohana Health Plan Medicare	$22.35
Rate for Payer: Ohana Health Plan Medicare	$4.00
Rate for Payer: UnitedHealthcare Medicaid	$4.81
Rate for Payer: UnitedHealthcare Medicaid	$26.82
Rate for Payer: UnitedHealthcare Medicare	$22.35
Rate for Payer: UnitedHealthcare Medicare	$4.00
Rate for Payer: University Health Alliance Commercial	$32.58
Rate for Payer: University Health Alliance Commercial	$5.84

haloperidol 5mg/1ml vial [HHSC]

Facility

$44.70

Service Code	HCPCS J1630
Hospital Charge Code	2500372
Hospital Revenue Code	250
Min. Negotiated Rate	$37.99
Max. Negotiated Rate	$43.36
Rate for Payer: Cash Price	$29.06
Rate for Payer: Cash Price	$5.21
Rate for Payer: Health Management Network Commercial	$37.99
Rate for Payer: Health Management Network Commercial	$6.81
Rate for Payer: Kaiser Permanente Commercial	$40.23
Rate for Payer: Kaiser Permanente Commercial	$7.21
Rate for Payer: MDX Hawaii PPO	$7.77
Rate for Payer: MDX Hawaii PPO	$43.36

haloperidol 5 mg tablet [HHSC]

Facility

$6.07

Service Code	NDC 51079073620
Hospital Charge Code	2500371
Hospital Revenue Code	250
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$5.89
Rate for Payer: AlohaCare Medicaid	$3.04
Rate for Payer: AlohaCare Medicare	$3.04
Rate for Payer: Cash Price	$3.95
Rate for Payer: Devoted Health Medicare	$3.34
Rate for Payer: Hawaii Medical Service Association Medicare	$3.04
Rate for Payer: Hawaii Western Management Group Commercial	$5.77
Rate for Payer: Health Management Network Commercial	$5.16
Rate for Payer: Humana Medicare	$3.04
Rate for Payer: Kaiser Permanente Commercial	$5.46
Rate for Payer: Kaiser Permanente Medicaid	$3.10
Rate for Payer: Kaiser Permanente Medicare	$3.04
Rate for Payer: MDX Hawaii PPO	$5.89
Rate for Payer: Ohana Health Plan Medicaid	$3.04
Rate for Payer: Ohana Health Plan Medicare	$3.04
Rate for Payer: UnitedHealthcare Medicaid	$3.64
Rate for Payer: UnitedHealthcare Medicare	$3.04
Rate for Payer: University Health Alliance Commercial	$4.42

haloperidol 5 mg tablet [HHSC]

Facility

$5.69

Service Code	NDC 68382007901
Hospital Charge Code	2500371
Hospital Revenue Code	250
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$5.52
Rate for Payer: Cash Price	$3.70
Rate for Payer: Health Management Network Commercial	$4.84
Rate for Payer: Kaiser Permanente Commercial	$5.12
Rate for Payer: MDX Hawaii PPO	$5.52

haloperidol 5 mg tablet [HHSC]

Facility

$5.69

Service Code	NDC 68382007901
Hospital Charge Code	2500371
Hospital Revenue Code	250
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$5.52
Rate for Payer: AlohaCare Medicaid	$2.85
Rate for Payer: AlohaCare Medicare	$2.85
Rate for Payer: Cash Price	$3.70
Rate for Payer: Devoted Health Medicare	$3.13
Rate for Payer: Hawaii Medical Service Association Medicare	$2.85
Rate for Payer: Hawaii Western Management Group Commercial	$5.41
Rate for Payer: Health Management Network Commercial	$4.84
Rate for Payer: Humana Medicare	$2.85
Rate for Payer: Kaiser Permanente Commercial	$5.12
Rate for Payer: Kaiser Permanente Medicaid	$2.90
Rate for Payer: Kaiser Permanente Medicare	$2.85
Rate for Payer: MDX Hawaii PPO	$5.52
Rate for Payer: Ohana Health Plan Medicaid	$2.85
Rate for Payer: Ohana Health Plan Medicare	$2.85
Rate for Payer: UnitedHealthcare Medicaid	$3.41
Rate for Payer: UnitedHealthcare Medicare	$2.85
Rate for Payer: University Health Alliance Commercial	$4.15

haloperidol 5 mg tablet [HHSC]

Facility

$6.07

Service Code	NDC 51079073620
Hospital Charge Code	2500371
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$5.89
Rate for Payer: Cash Price	$3.95
Rate for Payer: Health Management Network Commercial	$5.16
Rate for Payer: Kaiser Permanente Commercial	$5.46
Rate for Payer: MDX Hawaii PPO	$5.89

haloperidol 5 mg tablet [HHSC]

Facility

$4.50

Service Code	NDC 60687016101
Hospital Charge Code	2500371
Hospital Revenue Code	250
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$4.37
Rate for Payer: AlohaCare Medicaid	$2.25
Rate for Payer: AlohaCare Medicare	$2.25
Rate for Payer: Cash Price	$2.92
Rate for Payer: Devoted Health Medicare	$2.48
Rate for Payer: Hawaii Medical Service Association Medicare	$2.25
Rate for Payer: Hawaii Western Management Group Commercial	$4.28
Rate for Payer: Health Management Network Commercial	$3.83
Rate for Payer: Humana Medicare	$2.25
Rate for Payer: Kaiser Permanente Commercial	$4.05
Rate for Payer: Kaiser Permanente Medicaid	$2.29
Rate for Payer: Kaiser Permanente Medicare	$2.25
Rate for Payer: MDX Hawaii PPO	$4.37
Rate for Payer: Ohana Health Plan Medicaid	$2.25
Rate for Payer: Ohana Health Plan Medicare	$2.25
Rate for Payer: UnitedHealthcare Medicaid	$2.70
Rate for Payer: UnitedHealthcare Medicare	$2.25
Rate for Payer: University Health Alliance Commercial	$3.28

haloperidol 5 mg tablet [HHSC]

Facility

$4.50

Service Code	NDC 60687016101
Hospital Charge Code	2500371
Hospital Revenue Code	250
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$4.37
Rate for Payer: Cash Price	$2.92
Rate for Payer: Health Management Network Commercial	$3.83
Rate for Payer: Kaiser Permanente Commercial	$4.05
Rate for Payer: MDX Hawaii PPO	$4.37

haloperidol decan 100 mg/1ml vial [HHSC]

Facility

$315.42

Service Code	HCPCS J1631
Hospital Charge Code	2500373
Hospital Revenue Code	250
Min. Negotiated Rate	$268.11
Max. Negotiated Rate	$305.96
Rate for Payer: Cash Price	$205.02
Rate for Payer: Cash Price	$196.93
Rate for Payer: Cash Price	$183.90
Rate for Payer: Health Management Network Commercial	$240.48
Rate for Payer: Health Management Network Commercial	$268.11
Rate for Payer: Health Management Network Commercial	$257.52
Rate for Payer: Kaiser Permanente Commercial	$272.67
Rate for Payer: Kaiser Permanente Commercial	$283.88
Rate for Payer: Kaiser Permanente Commercial	$254.63
Rate for Payer: MDX Hawaii PPO	$293.88
Rate for Payer: MDX Hawaii PPO	$274.43
Rate for Payer: MDX Hawaii PPO	$305.96

haloperidol decan 100 mg/1ml vial [HHSC]

Facility

$282.92

Service Code	HCPCS J1631
Hospital Charge Code	2500373
Hospital Revenue Code	636
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$274.43
Rate for Payer: AlohaCare Medicaid	$141.46
Rate for Payer: AlohaCare Medicaid	$157.71
Rate for Payer: AlohaCare Medicaid	$151.49
Rate for Payer: AlohaCare Medicare	$151.49
Rate for Payer: AlohaCare Medicare	$141.46
Rate for Payer: AlohaCare Medicare	$157.71
Rate for Payer: Cash Price	$196.93
Rate for Payer: Cash Price	$205.02
Rate for Payer: Cash Price	$196.93
Rate for Payer: Cash Price	$183.90
Rate for Payer: Cash Price	$183.90
Rate for Payer: Cash Price	$205.02
Rate for Payer: Devoted Health Medicare	$155.61
Rate for Payer: Devoted Health Medicare	$173.48
Rate for Payer: Devoted Health Medicare	$166.63
Rate for Payer: Hawaii Medical Service Association ABD	$4.68
Rate for Payer: Hawaii Medical Service Association ABD	$4.68
Rate for Payer: Hawaii Medical Service Association ABD	$4.68
Rate for Payer: Hawaii Medical Service Association Medicare	$141.46
Rate for Payer: Hawaii Medical Service Association Medicare	$157.71
Rate for Payer: Hawaii Medical Service Association Medicare	$151.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.68
Rate for Payer: Hawaii Western Management Group Commercial	$287.82
Rate for Payer: Hawaii Western Management Group Commercial	$268.77
Rate for Payer: Hawaii Western Management Group Commercial	$299.65
Rate for Payer: Health Management Network Commercial	$268.11
Rate for Payer: Health Management Network Commercial	$240.48
Rate for Payer: Health Management Network Commercial	$257.52
Rate for Payer: Humana Medicare	$141.46
Rate for Payer: Humana Medicare	$151.49
Rate for Payer: Humana Medicare	$157.71
Rate for Payer: Kaiser Permanente Commercial	$254.63
Rate for Payer: Kaiser Permanente Commercial	$272.67
Rate for Payer: Kaiser Permanente Commercial	$283.88
Rate for Payer: Kaiser Permanente Medicaid	$160.86
Rate for Payer: Kaiser Permanente Medicaid	$154.51
Rate for Payer: Kaiser Permanente Medicaid	$144.29
Rate for Payer: Kaiser Permanente Medicare	$141.46
Rate for Payer: Kaiser Permanente Medicare	$151.49
Rate for Payer: Kaiser Permanente Medicare	$157.71
Rate for Payer: MDX Hawaii PPO	$305.96
Rate for Payer: MDX Hawaii PPO	$293.88
Rate for Payer: MDX Hawaii PPO	$274.43
Rate for Payer: Ohana Health Plan Medicaid	$151.49
Rate for Payer: Ohana Health Plan Medicaid	$141.46
Rate for Payer: Ohana Health Plan Medicaid	$157.71
Rate for Payer: Ohana Health Plan Medicare	$151.49
Rate for Payer: Ohana Health Plan Medicare	$141.46
Rate for Payer: Ohana Health Plan Medicare	$157.71
Rate for Payer: UnitedHealthcare Medicaid	$181.78
Rate for Payer: UnitedHealthcare Medicaid	$169.75
Rate for Payer: UnitedHealthcare Medicaid	$189.25
Rate for Payer: UnitedHealthcare Medicare	$151.49
Rate for Payer: UnitedHealthcare Medicare	$141.46
Rate for Payer: UnitedHealthcare Medicare	$157.71
Rate for Payer: University Health Alliance Commercial	$206.22
Rate for Payer: University Health Alliance Commercial	$220.83
Rate for Payer: University Health Alliance Commercial	$229.91

Hand finger orthosis, w/o joint, prefab (Carrot splint L)

Facility

$135.00

Service Code	HCPCS L3924
Hospital Charge Code	13381794
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$67.50
Rate for Payer: AlohaCare Medicare	$67.50
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Devoted Health Medicare	$74.25
Rate for Payer: Hawaii Medical Service Association Medicare	$67.50
Rate for Payer: Hawaii Western Management Group Commercial	$94.50
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$67.50
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$67.50
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$67.50
Rate for Payer: Ohana Health Plan Medicare	$67.50
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$67.50
Rate for Payer: University Health Alliance Commercial	$75.60

Hand finger orthosis, w/o joint, prefab (Carrot splint L)

Facility

$135.00

Service Code	HCPCS L3924
Hospital Charge Code	13381794
Hospital Revenue Code	274
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$87.75
Rate for Payer: Hawaii Western Management Group Commercial	$94.50
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: University Health Alliance Commercial	$75.60

Hand finger orthosis, w/o joint, prefab (Carrot splint; S)

Facility

$135.00

Service Code	HCPCS L3924
Hospital Charge Code	13381791
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$67.50
Rate for Payer: AlohaCare Medicare	$67.50
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Devoted Health Medicare	$74.25
Rate for Payer: Hawaii Medical Service Association Medicare	$67.50
Rate for Payer: Hawaii Western Management Group Commercial	$94.50
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$67.50
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$67.50
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$67.50
Rate for Payer: Ohana Health Plan Medicare	$67.50
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$67.50
Rate for Payer: University Health Alliance Commercial	$75.60

Hand finger orthosis, w/o joint, prefab (Carrot splint; S)

Facility

$135.00

Service Code	HCPCS L3924
Hospital Charge Code	13381791
Hospital Revenue Code	274
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$87.75
Rate for Payer: Hawaii Western Management Group Commercial	$94.50
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: University Health Alliance Commercial	$75.60

Hand finger orthosis, w/o joint, prefab (CMC brace; 0 L)

Facility

$388.00

Service Code	HCPCS L3924
Hospital Charge Code	13372155
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$376.36
Rate for Payer: AlohaCare Medicaid	$194.00
Rate for Payer: AlohaCare Medicare	$194.00
Rate for Payer: Cash Price	$252.20
Rate for Payer: Cash Price	$252.20
Rate for Payer: Devoted Health Medicare	$213.40
Rate for Payer: Hawaii Medical Service Association Medicare	$194.00
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Humana Medicare	$194.00
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: Kaiser Permanente Medicaid	$197.88
Rate for Payer: Kaiser Permanente Medicare	$194.00
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: Ohana Health Plan Medicaid	$194.00
Rate for Payer: Ohana Health Plan Medicare	$194.00
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$194.00
Rate for Payer: University Health Alliance Commercial	$217.28

Hand finger orthosis, w/o joint, prefab (CMC brace; 0 L)

Facility

$388.00

Service Code	HCPCS L3924
Hospital Charge Code	13372155
Hospital Revenue Code	274
Min. Negotiated Rate	$217.28
Max. Negotiated Rate	$376.36
Rate for Payer: Cash Price	$252.20
Rate for Payer: Hawaii Western Management Group Commercial	$271.60
Rate for Payer: Health Management Network Commercial	$329.80
Rate for Payer: Kaiser Permanente Commercial	$349.20
Rate for Payer: MDX Hawaii PPO	$376.36
Rate for Payer: University Health Alliance Commercial	$217.28

Hand finger orthosis, w/o joint, prefab (CMC brace; 0 R)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372151
Hospital Revenue Code	274
Min. Negotiated Rate	$206.08
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 0 R)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372151
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$184.00
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$202.40
Rate for Payer: Hawaii Medical Service Association Medicare	$184.00
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$184.00
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$184.00
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$184.00
Rate for Payer: Ohana Health Plan Medicare	$184.00
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$184.00
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 1 L)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372152
Hospital Revenue Code	274
Min. Negotiated Rate	$206.08
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 1 L)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372152
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$184.00
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$202.40
Rate for Payer: Hawaii Medical Service Association Medicare	$184.00
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$184.00
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$184.00
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$184.00
Rate for Payer: Ohana Health Plan Medicare	$184.00
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$184.00
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 1 R)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13381795
Hospital Revenue Code	274
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$356.96
Rate for Payer: AlohaCare Medicaid	$184.00
Rate for Payer: AlohaCare Medicare	$184.00
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Devoted Health Medicare	$202.40
Rate for Payer: Hawaii Medical Service Association Medicare	$184.00
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Humana Medicare	$184.00
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: Kaiser Permanente Medicaid	$187.68
Rate for Payer: Kaiser Permanente Medicare	$184.00
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: Ohana Health Plan Medicaid	$184.00
Rate for Payer: Ohana Health Plan Medicare	$184.00
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$184.00
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 1 R)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13381795
Hospital Revenue Code	274
Min. Negotiated Rate	$206.08
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: University Health Alliance Commercial	$206.08

Hand finger orthosis, w/o joint, prefab (CMC brace; 2 L)

Facility

$368.00

Service Code	HCPCS L3924
Hospital Charge Code	13372153
Hospital Revenue Code	274
Min. Negotiated Rate	$206.08
Max. Negotiated Rate	$356.96
Rate for Payer: Cash Price	$239.20
Rate for Payer: Hawaii Western Management Group Commercial	$257.60
Rate for Payer: Health Management Network Commercial	$312.80
Rate for Payer: Kaiser Permanente Commercial	$331.20
Rate for Payer: MDX Hawaii PPO	$356.96
Rate for Payer: University Health Alliance Commercial	$206.08

Know your out-of-pocket cost for care.

All Charges