Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ TechFee

Facility

$843.00

Service Code	HCPCS 28510
Hospital Charge Code	8023309
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

28510 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ TechFee

Facility

$843.00

Service Code	HCPCS 28510
Hospital Charge Code	8023309
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

28510-Phalanx w/o Manipulation; Not Great Toe

Facility

$773.00

Service Code	HCPCS 28510
Hospital Charge Code	8080132
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

28510-Phalanx w/o Manipulation; Not Great Toe

Facility

$773.00

Service Code	HCPCS 28510
Hospital Charge Code	8080132
Hospital Revenue Code	450
Min. Negotiated Rate	$386.50
Max. Negotiated Rate	$1,600.00
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	$563.44

28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TechFee

Facility

$823.00

Service Code	HCPCS 28515
Hospital Charge Code	8023310
Hospital Revenue Code	450
Min. Negotiated Rate	$411.50
Max. Negotiated Rate	$1,600.00
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	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$411.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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

28515 CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ TechFee

Facility

$823.00

Service Code	HCPCS 28515
Hospital Charge Code	8023310
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

28515-Phalanx w/ Manipulation; Not Great Toe

Facility

$848.00

Service Code	HCPCS 28515
Hospital Charge Code	8080134
Hospital Revenue Code	450
Min. Negotiated Rate	$424.00
Max. Negotiated Rate	$1,600.00
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	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$424.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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

28515-Phalanx w/ Manipulation; Not Great Toe

Facility

$848.00

Service Code	HCPCS 28515
Hospital Charge Code	8080134
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

28630-Metatarsophalangeal w/o Anesthesia

Facility

$1,434.00

Service Code	HCPCS 28630
Hospital Charge Code	8080098
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

28630-Metatarsophalangeal w/o Anesthesia

Facility

$1,434.00

Service Code	HCPCS 28630
Hospital Charge Code	8080098
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

28660 CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES TechFee

Facility

$823.00

Service Code	HCPCS 28660
Hospital Charge Code	8023320
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

28660 CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES TechFee

Facility

$823.00

Service Code	HCPCS 28660
Hospital Charge Code	8023320
Hospital Revenue Code	450
Min. Negotiated Rate	$411.50
Max. Negotiated Rate	$1,600.00
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	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$411.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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

28660-Interphalangeal Foot w/o Anesthesia

Facility

$848.00

Service Code	HCPCS 28660
Hospital Charge Code	8080100
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

28660-Interphalangeal Foot w/o Anesthesia

Facility

$848.00

Service Code	HCPCS 28660
Hospital Charge Code	8080100
Hospital Revenue Code	450
Min. Negotiated Rate	$424.00
Max. Negotiated Rate	$1,600.00
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	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$424.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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

28810 Amputation, metatarsal, with toe, single

Professional

Both

$1,382.00

Service Code	HCPCS 28810
Hospital Charge Code	8038428
Hospital Revenue Code	975
Min. Negotiated Rate	$403.67
Max. Negotiated Rate	$1,174.70
Rate for Payer: AlohaCare Medicaid	$434.96
Rate for Payer: AlohaCare Medicare	$403.67
Rate for Payer: Cash Price	$898.30
Rate for Payer: Cash Price	$898.30
Rate for Payer: Devoted Health Medicare	$444.04
Rate for Payer: Hawaii Medical Service Association Medicare	$403.67
Rate for Payer: Hawaii Western Management Group Commercial	$413.40
Rate for Payer: Health Management Network Commercial	$1,174.70
Rate for Payer: Kaiser Permanente Commercial	$444.04
Rate for Payer: Kaiser Permanente Medicaid	$444.04
Rate for Payer: Kaiser Permanente Medicare	$444.04
Rate for Payer: Ohana Health Plan Medicaid	$434.96
Rate for Payer: Ohana Health Plan Medicare	$403.67
Rate for Payer: UnitedHealthcare Medicaid	$434.96
Rate for Payer: UnitedHealthcare Medicare	$403.67

28825 Amputation, toe; interphalangeal joint

Professional

Both

$4,554.00

Service Code	HCPCS 28825
Hospital Charge Code	8038430
Hospital Revenue Code	975
Min. Negotiated Rate	$152.36
Max. Negotiated Rate	$3,870.90
Rate for Payer: AlohaCare Medicaid	$173.00
Rate for Payer: AlohaCare Medicare	$155.27
Rate for Payer: Cash Price	$2,960.10
Rate for Payer: Cash Price	$2,960.10
Rate for Payer: Devoted Health Medicare	$170.80
Rate for Payer: Hawaii Medical Service Association ABD	$173.00
Rate for Payer: Hawaii Medical Service Association Commercial	$437.69
Rate for Payer: Hawaii Medical Service Association Medicare	$155.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$173.00
Rate for Payer: Hawaii Western Management Group Commercial	$152.36
Rate for Payer: Health Management Network Commercial	$3,870.90
Rate for Payer: Kaiser Permanente Commercial	$170.80
Rate for Payer: Kaiser Permanente Medicaid	$170.80
Rate for Payer: Kaiser Permanente Medicare	$170.80
Rate for Payer: Ohana Health Plan Medicaid	$173.00
Rate for Payer: Ohana Health Plan Medicare	$155.27
Rate for Payer: UnitedHealthcare Medicaid	$173.00
Rate for Payer: UnitedHealthcare Medicare	$155.27
Rate for Payer: University Health Alliance Commercial	$228.04

29055 Application of Shoulder Cast TechFee

Facility

$1,463.00

Service Code	HCPCS 29055
Hospital Charge Code	8343970
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	$731.50
Rate for Payer: Cash Price	$950.95
Rate for Payer: Cash Price	$950.95
Rate for Payer: Cash Price	$950.95
Rate for Payer: Devoted Health Medicare	$804.65
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	$731.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,389.85
Rate for Payer: Health Management Network Commercial	$1,243.55
Rate for Payer: Humana Medicare	$731.50
Rate for Payer: Kaiser Permanente Commercial	$1,316.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$731.50
Rate for Payer: MDX Hawaii PPO	$1,419.11
Rate for Payer: Ohana Health Plan Medicaid	$731.50
Rate for Payer: Ohana Health Plan Medicare	$731.50
Rate for Payer: UnitedHealthcare Medicare	$731.50
Rate for Payer: University Health Alliance Commercial	$1,066.38

29055 Application of Shoulder Cast TechFee

Facility

$1,463.00

Service Code	HCPCS 29055
Hospital Charge Code	8343970
Hospital Revenue Code	450
Min. Negotiated Rate	$1,243.55
Max. Negotiated Rate	$1,419.11
Rate for Payer: Cash Price	$950.95
Rate for Payer: Health Management Network Commercial	$1,243.55
Rate for Payer: Kaiser Permanente Commercial	$1,316.70
Rate for Payer: MDX Hawaii PPO	$1,419.11

29075 APPLICATION CAST ELBOW FINGER SHORT ARM TechFee

Facility

$1,058.00

Service Code	HCPCS 29075
Hospital Charge Code	8023334
Hospital Revenue Code	450
Min. Negotiated Rate	$899.30
Max. Negotiated Rate	$1,026.26
Rate for Payer: Cash Price	$687.70
Rate for Payer: Health Management Network Commercial	$899.30
Rate for Payer: Kaiser Permanente Commercial	$952.20
Rate for Payer: MDX Hawaii PPO	$1,026.26

29075 APPLICATION CAST ELBOW FINGER SHORT ARM TechFee

Facility

$1,058.00

Service Code	HCPCS 29075
Hospital Charge Code	8023334
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	$529.00
Rate for Payer: Cash Price	$687.70
Rate for Payer: Cash Price	$687.70
Rate for Payer: Cash Price	$687.70
Rate for Payer: Devoted Health Medicare	$581.90
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	$529.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,005.10
Rate for Payer: Health Management Network Commercial	$899.30
Rate for Payer: Humana Medicare	$529.00
Rate for Payer: Kaiser Permanente Commercial	$952.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$529.00
Rate for Payer: MDX Hawaii PPO	$1,026.26
Rate for Payer: Ohana Health Plan Medicaid	$529.00
Rate for Payer: Ohana Health Plan Medicare	$529.00
Rate for Payer: UnitedHealthcare Medicare	$529.00
Rate for Payer: University Health Alliance Commercial	$771.18

29105 APPLICATION LONG ARM SPLINT (SHOULDER TO HAND)

Facility

$613.00

Service Code	HCPCS 29105
Hospital Charge Code	8023336
Hospital Revenue Code	450
Min. Negotiated Rate	$521.05
Max. Negotiated Rate	$594.61
Rate for Payer: Cash Price	$398.45
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Kaiser Permanente Commercial	$551.70
Rate for Payer: MDX Hawaii PPO	$594.61

29105 APPLICATION LONG ARM SPLINT (SHOULDER TO HAND)

Facility

$613.00

Service Code	HCPCS 29105
Hospital Charge Code	8023336
Hospital Revenue Code	450
Min. Negotiated Rate	$306.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$306.50
Rate for Payer: Cash Price	$398.45
Rate for Payer: Cash Price	$398.45
Rate for Payer: Cash Price	$398.45
Rate for Payer: Devoted Health Medicare	$337.15
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	$306.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$582.35
Rate for Payer: Health Management Network Commercial	$521.05
Rate for Payer: Humana Medicare	$306.50
Rate for Payer: Kaiser Permanente Commercial	$551.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$306.50
Rate for Payer: MDX Hawaii PPO	$594.61
Rate for Payer: Ohana Health Plan Medicaid	$306.50
Rate for Payer: Ohana Health Plan Medicare	$306.50
Rate for Payer: UnitedHealthcare Medicare	$306.50
Rate for Payer: University Health Alliance Commercial	$446.82

29105 Application of long arm splint (shoulder to hand)

Professional

Both

$318.00

Service Code	HCPCS 29105
Hospital Charge Code	8038439
Hospital Revenue Code	975
Min. Negotiated Rate	$36.18
Max. Negotiated Rate	$270.30
Rate for Payer: AlohaCare Medicaid	$40.71
Rate for Payer: AlohaCare Medicare	$36.18
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$39.80
Rate for Payer: Hawaii Medical Service Association ABD	$40.71
Rate for Payer: Hawaii Medical Service Association Commercial	$88.31
Rate for Payer: Hawaii Medical Service Association Medicare	$36.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$40.71
Rate for Payer: Hawaii Western Management Group Commercial	$71.50
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$39.80
Rate for Payer: Kaiser Permanente Medicaid	$39.80
Rate for Payer: Kaiser Permanente Medicare	$39.80
Rate for Payer: Ohana Health Plan Medicaid	$40.71
Rate for Payer: Ohana Health Plan Medicare	$36.18
Rate for Payer: UnitedHealthcare Medicaid	$40.71
Rate for Payer: UnitedHealthcare Medicare	$36.18
Rate for Payer: University Health Alliance Commercial	$50.24

29105-Long Arm

Facility

$533.00

Service Code	HCPCS 29105
Hospital Charge Code	8080071
Hospital Revenue Code	450
Min. Negotiated Rate	$266.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$266.50
Rate for Payer: Cash Price	$346.45
Rate for Payer: Cash Price	$346.45
Rate for Payer: Cash Price	$346.45
Rate for Payer: Devoted Health Medicare	$293.15
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	$266.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$506.35
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Humana Medicare	$266.50
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$266.50
Rate for Payer: MDX Hawaii PPO	$517.01
Rate for Payer: Ohana Health Plan Medicaid	$266.50
Rate for Payer: Ohana Health Plan Medicare	$266.50
Rate for Payer: UnitedHealthcare Medicare	$266.50
Rate for Payer: University Health Alliance Commercial	$388.50

29105-Long Arm

Facility

$533.00

Service Code	HCPCS 29105
Hospital Charge Code	8080071
Hospital Revenue Code	450
Min. Negotiated Rate	$453.05
Max. Negotiated Rate	$517.01
Rate for Payer: Cash Price	$346.45
Rate for Payer: Health Management Network Commercial	$453.05
Rate for Payer: Kaiser Permanente Commercial	$479.70
Rate for Payer: MDX Hawaii PPO	$517.01

Know your out-of-pocket cost for care.

All Charges