Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

41250-Mouth Floor/Tongue Ant 2/3 Less Than/Equal to 2.5cm

Facility

$809.00

Service Code	HCPCS 41250
Hospital Charge Code	8080039
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	$404.50
Rate for Payer: Cash Price	$525.85
Rate for Payer: Cash Price	$525.85
Rate for Payer: Cash Price	$525.85
Rate for Payer: Devoted Health Medicare	$444.95
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	$404.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$768.55
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: Humana Medicare	$404.50
Rate for Payer: Kaiser Permanente Commercial	$728.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$404.50
Rate for Payer: MDX Hawaii PPO	$784.73
Rate for Payer: Ohana Health Plan Medicaid	$404.50
Rate for Payer: Ohana Health Plan Medicare	$404.50
Rate for Payer: UnitedHealthcare Medicare	$404.50
Rate for Payer: University Health Alliance Commercial	$589.68

41250 RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG TechFee

Facility

$879.00

Service Code	HCPCS 41250
Hospital Charge Code	8211317
Hospital Revenue Code	450
Min. Negotiated Rate	$747.15
Max. Negotiated Rate	$852.63
Rate for Payer: Cash Price	$571.35
Rate for Payer: Health Management Network Commercial	$747.15
Rate for Payer: Kaiser Permanente Commercial	$791.10
Rate for Payer: MDX Hawaii PPO	$852.63

41250 RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG TechFee

Facility

$879.00

Service Code	HCPCS 41250
Hospital Charge Code	8211317
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	$439.50
Rate for Payer: Cash Price	$571.35
Rate for Payer: Cash Price	$571.35
Rate for Payer: Cash Price	$571.35
Rate for Payer: Devoted Health Medicare	$483.45
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	$439.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$835.05
Rate for Payer: Health Management Network Commercial	$747.15
Rate for Payer: Humana Medicare	$439.50
Rate for Payer: Kaiser Permanente Commercial	$791.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$439.50
Rate for Payer: MDX Hawaii PPO	$852.63
Rate for Payer: Ohana Health Plan Medicaid	$439.50
Rate for Payer: Ohana Health Plan Medicare	$439.50
Rate for Payer: UnitedHealthcare Medicare	$439.50
Rate for Payer: University Health Alliance Commercial	$640.70

41251-MF/T Posterior 1/3 Less Than/Equal to 2.5 cm

Facility

$1,316.00

Service Code	HCPCS 41251
Hospital Charge Code	8080038
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	$658.00
Rate for Payer: Cash Price	$855.40
Rate for Payer: Cash Price	$855.40
Rate for Payer: Cash Price	$855.40
Rate for Payer: Devoted Health Medicare	$723.80
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	$658.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,250.20
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Humana Medicare	$658.00
Rate for Payer: Kaiser Permanente Commercial	$1,184.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$658.00
Rate for Payer: MDX Hawaii PPO	$1,276.52
Rate for Payer: Ohana Health Plan Medicaid	$658.00
Rate for Payer: Ohana Health Plan Medicare	$658.00
Rate for Payer: UnitedHealthcare Medicare	$658.00
Rate for Payer: University Health Alliance Commercial	$959.23

41251-MF/T Posterior 1/3 Less Than/Equal to 2.5 cm

Facility

$1,316.00

Service Code	HCPCS 41251
Hospital Charge Code	8080038
Hospital Revenue Code	450
Min. Negotiated Rate	$1,118.60
Max. Negotiated Rate	$1,276.52
Rate for Payer: Cash Price	$855.40
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Kaiser Permanente Commercial	$1,184.40
Rate for Payer: MDX Hawaii PPO	$1,276.52

41252-MF/T Complex 1/3 Greater Than 2.6cm

Facility

$1,316.00

Service Code	HCPCS 41252
Hospital Charge Code	8080040
Hospital Revenue Code	450
Min. Negotiated Rate	$1,118.60
Max. Negotiated Rate	$1,276.52
Rate for Payer: Cash Price	$855.40
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Kaiser Permanente Commercial	$1,184.40
Rate for Payer: MDX Hawaii PPO	$1,276.52

41252-MF/T Complex 1/3 Greater Than 2.6cm

Facility

$1,316.00

Service Code	HCPCS 41252
Hospital Charge Code	8080040
Hospital Revenue Code	450
Min. Negotiated Rate	$658.00
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$658.00
Rate for Payer: Cash Price	$855.40
Rate for Payer: Cash Price	$855.40
Rate for Payer: Devoted Health Medicare	$723.80
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	$658.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,250.20
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Humana Medicare	$658.00
Rate for Payer: Kaiser Permanente Commercial	$1,184.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$658.00
Rate for Payer: MDX Hawaii PPO	$1,276.52
Rate for Payer: Ohana Health Plan Medicaid	$658.00
Rate for Payer: Ohana Health Plan Medicare	$658.00
Rate for Payer: UnitedHealthcare Medicare	$658.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

41800-Drainage Abscess/Cyst Dentoalveolar

Facility

$803.00

Service Code	HCPCS 41800
Hospital Charge Code	8080046
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	$401.50
Rate for Payer: Cash Price	$521.95
Rate for Payer: Cash Price	$521.95
Rate for Payer: Cash Price	$521.95
Rate for Payer: Devoted Health Medicare	$441.65
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	$401.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$762.85
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Humana Medicare	$401.50
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$401.50
Rate for Payer: MDX Hawaii PPO	$778.91
Rate for Payer: Ohana Health Plan Medicaid	$401.50
Rate for Payer: Ohana Health Plan Medicare	$401.50
Rate for Payer: UnitedHealthcare Medicare	$401.50
Rate for Payer: University Health Alliance Commercial	$585.31

41800-Drainage Abscess/Cyst Dentoalveolar

Facility

$803.00

Service Code	HCPCS 41800
Hospital Charge Code	8080046
Hospital Revenue Code	450
Min. Negotiated Rate	$682.55
Max. Negotiated Rate	$778.91
Rate for Payer: Cash Price	$521.95
Rate for Payer: Health Management Network Commercial	$682.55
Rate for Payer: Kaiser Permanente Commercial	$722.70
Rate for Payer: MDX Hawaii PPO	$778.91

41800 DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS TechFee

Facility

$873.00

Service Code	HCPCS 41800
Hospital Charge Code	8211318
Hospital Revenue Code	450
Min. Negotiated Rate	$742.05
Max. Negotiated Rate	$846.81
Rate for Payer: Cash Price	$567.45
Rate for Payer: Health Management Network Commercial	$742.05
Rate for Payer: Kaiser Permanente Commercial	$785.70
Rate for Payer: MDX Hawaii PPO	$846.81

41800 DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS TechFee

Facility

$873.00

Service Code	HCPCS 41800
Hospital Charge Code	8211318
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	$436.50
Rate for Payer: Cash Price	$567.45
Rate for Payer: Cash Price	$567.45
Rate for Payer: Cash Price	$567.45
Rate for Payer: Devoted Health Medicare	$480.15
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	$436.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$829.35
Rate for Payer: Health Management Network Commercial	$742.05
Rate for Payer: Humana Medicare	$436.50
Rate for Payer: Kaiser Permanente Commercial	$785.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$436.50
Rate for Payer: MDX Hawaii PPO	$846.81
Rate for Payer: Ohana Health Plan Medicaid	$436.50
Rate for Payer: Ohana Health Plan Medicare	$436.50
Rate for Payer: UnitedHealthcare Medicare	$436.50
Rate for Payer: University Health Alliance Commercial	$636.33

41899 UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES

Facility

$661.00

Service Code	HCPCS 41899
Hospital Charge Code	8258855
Hospital Revenue Code	450
Min. Negotiated Rate	$561.85
Max. Negotiated Rate	$641.17
Rate for Payer: Cash Price	$429.65
Rate for Payer: Health Management Network Commercial	$561.85
Rate for Payer: Kaiser Permanente Commercial	$594.90
Rate for Payer: MDX Hawaii PPO	$641.17

41899 UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES

Facility

$661.00

Service Code	HCPCS 41899
Hospital Charge Code	8258855
Hospital Revenue Code	450
Min. Negotiated Rate	$330.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$330.50
Rate for Payer: Cash Price	$429.65
Rate for Payer: Cash Price	$429.65
Rate for Payer: Cash Price	$429.65
Rate for Payer: Devoted Health Medicare	$363.55
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	$330.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$627.95
Rate for Payer: Health Management Network Commercial	$561.85
Rate for Payer: Humana Medicare	$330.50
Rate for Payer: Kaiser Permanente Commercial	$594.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$330.50
Rate for Payer: MDX Hawaii PPO	$641.17
Rate for Payer: Ohana Health Plan Medicaid	$330.50
Rate for Payer: Ohana Health Plan Medicare	$330.50
Rate for Payer: UnitedHealthcare Medicare	$330.50
Rate for Payer: University Health Alliance Commercial	$481.80

42000-Drainage Abscess Palate/Uvula

Facility

$1,316.00

Service Code	HCPCS 42000
Hospital Charge Code	8080048
Hospital Revenue Code	450
Min. Negotiated Rate	$1,118.60
Max. Negotiated Rate	$1,276.52
Rate for Payer: Cash Price	$855.40
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Kaiser Permanente Commercial	$1,184.40
Rate for Payer: MDX Hawaii PPO	$1,276.52

42000-Drainage Abscess Palate/Uvula

Facility

$1,316.00

Service Code	HCPCS 42000
Hospital Charge Code	8080048
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	$658.00
Rate for Payer: Cash Price	$855.40
Rate for Payer: Cash Price	$855.40
Rate for Payer: Cash Price	$855.40
Rate for Payer: Devoted Health Medicare	$723.80
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	$658.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,250.20
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Humana Medicare	$658.00
Rate for Payer: Kaiser Permanente Commercial	$1,184.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$658.00
Rate for Payer: MDX Hawaii PPO	$1,276.52
Rate for Payer: Ohana Health Plan Medicaid	$658.00
Rate for Payer: Ohana Health Plan Medicare	$658.00
Rate for Payer: UnitedHealthcare Medicare	$658.00
Rate for Payer: University Health Alliance Commercial	$959.23

42200 Palatoplasty for cleft palate ProFee

Professional

Both

$8,239.00

Service Code	HCPCS 42200
Hospital Charge Code	9487224
Hospital Revenue Code	975
Min. Negotiated Rate	$581.88
Max. Negotiated Rate	$7,003.15
Rate for Payer: AlohaCare Medicaid	$957.45
Rate for Payer: AlohaCare Medicare	$859.93
Rate for Payer: Cash Price	$5,355.35
Rate for Payer: Cash Price	$5,355.35
Rate for Payer: Devoted Health Medicare	$945.92
Rate for Payer: Hawaii Medical Service Association Medicare	$859.93
Rate for Payer: Hawaii Western Management Group Commercial	$581.88
Rate for Payer: Health Management Network Commercial	$7,003.15
Rate for Payer: Kaiser Permanente Commercial	$945.92
Rate for Payer: Kaiser Permanente Medicaid	$945.92
Rate for Payer: Kaiser Permanente Medicare	$945.92
Rate for Payer: Ohana Health Plan Medicaid	$957.45
Rate for Payer: Ohana Health Plan Medicare	$859.93
Rate for Payer: UnitedHealthcare Medicaid	$957.45
Rate for Payer: UnitedHealthcare Medicare	$859.93

42700 I&D ABSCESS PERITONSILLAR TechFee

Facility

$1,652.00

Service Code	HCPCS 42700
Hospital Charge Code	8211321
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	$826.00
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Devoted Health Medicare	$908.60
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	$826.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,569.40
Rate for Payer: Health Management Network Commercial	$1,404.20
Rate for Payer: Humana Medicare	$826.00
Rate for Payer: Kaiser Permanente Commercial	$1,486.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$826.00
Rate for Payer: MDX Hawaii PPO	$1,602.44
Rate for Payer: Ohana Health Plan Medicaid	$826.00
Rate for Payer: Ohana Health Plan Medicare	$826.00
Rate for Payer: UnitedHealthcare Medicare	$826.00
Rate for Payer: University Health Alliance Commercial	$1,204.14

42700 I&D ABSCESS PERITONSILLAR TechFee

Facility

$1,652.00

Service Code	HCPCS 42700
Hospital Charge Code	8211321
Hospital Revenue Code	450
Min. Negotiated Rate	$1,404.20
Max. Negotiated Rate	$1,602.44
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Health Management Network Commercial	$1,404.20
Rate for Payer: Kaiser Permanente Commercial	$1,486.80
Rate for Payer: MDX Hawaii PPO	$1,602.44

42700-I&D Peritonsillar Abscess

Facility

$1,427.00

Service Code	HCPCS 42700
Hospital Charge Code	8080050
Hospital Revenue Code	450
Min. Negotiated Rate	$1,212.95
Max. Negotiated Rate	$1,384.19
Rate for Payer: Cash Price	$927.55
Rate for Payer: Health Management Network Commercial	$1,212.95
Rate for Payer: Kaiser Permanente Commercial	$1,284.30
Rate for Payer: MDX Hawaii PPO	$1,384.19

42700-I&D Peritonsillar Abscess

Facility

$1,427.00

Service Code	HCPCS 42700
Hospital Charge Code	8080050
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	$713.50
Rate for Payer: Cash Price	$927.55
Rate for Payer: Cash Price	$927.55
Rate for Payer: Cash Price	$927.55
Rate for Payer: Devoted Health Medicare	$784.85
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	$713.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,355.65
Rate for Payer: Health Management Network Commercial	$1,212.95
Rate for Payer: Humana Medicare	$713.50
Rate for Payer: Kaiser Permanente Commercial	$1,284.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$713.50
Rate for Payer: MDX Hawaii PPO	$1,384.19
Rate for Payer: Ohana Health Plan Medicaid	$713.50
Rate for Payer: Ohana Health Plan Medicare	$713.50
Rate for Payer: UnitedHealthcare Medicare	$713.50
Rate for Payer: University Health Alliance Commercial	$1,040.14

42809-Pharynx

Facility

$809.00

Service Code	HCPCS 42809
Hospital Charge Code	8080147
Hospital Revenue Code	450
Min. Negotiated Rate	$687.65
Max. Negotiated Rate	$784.73
Rate for Payer: Cash Price	$525.85
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: Kaiser Permanente Commercial	$728.10
Rate for Payer: MDX Hawaii PPO	$784.73

42809-Pharynx

Facility

$809.00

Service Code	HCPCS 42809
Hospital Charge Code	8080147
Hospital Revenue Code	450
Min. Negotiated Rate	$404.50
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$404.50
Rate for Payer: Cash Price	$525.85
Rate for Payer: Cash Price	$525.85
Rate for Payer: Cash Price	$525.85
Rate for Payer: Devoted Health Medicare	$444.95
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	$404.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$768.55
Rate for Payer: Health Management Network Commercial	$687.65
Rate for Payer: Humana Medicare	$404.50
Rate for Payer: Kaiser Permanente Commercial	$728.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$404.50
Rate for Payer: MDX Hawaii PPO	$784.73
Rate for Payer: Ohana Health Plan Medicaid	$404.50
Rate for Payer: Ohana Health Plan Medicare	$404.50
Rate for Payer: UnitedHealthcare Medicare	$404.50
Rate for Payer: University Health Alliance Commercial	$589.68

42809 REMOVAL FOREIGN BODY PHARYNX TechFee

Facility

$879.00

Service Code	HCPCS 42809
Hospital Charge Code	8211322
Hospital Revenue Code	450
Min. Negotiated Rate	$439.50
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$439.50
Rate for Payer: Cash Price	$571.35
Rate for Payer: Cash Price	$571.35
Rate for Payer: Cash Price	$571.35
Rate for Payer: Devoted Health Medicare	$483.45
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	$439.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$835.05
Rate for Payer: Health Management Network Commercial	$747.15
Rate for Payer: Humana Medicare	$439.50
Rate for Payer: Kaiser Permanente Commercial	$791.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$439.50
Rate for Payer: MDX Hawaii PPO	$852.63
Rate for Payer: Ohana Health Plan Medicaid	$439.50
Rate for Payer: Ohana Health Plan Medicare	$439.50
Rate for Payer: UnitedHealthcare Medicare	$439.50
Rate for Payer: University Health Alliance Commercial	$640.70

42809 REMOVAL FOREIGN BODY PHARYNX TechFee

Facility

$879.00

Service Code	HCPCS 42809
Hospital Charge Code	8211322
Hospital Revenue Code	450
Min. Negotiated Rate	$747.15
Max. Negotiated Rate	$852.63
Rate for Payer: Cash Price	$571.35
Rate for Payer: Health Management Network Commercial	$747.15
Rate for Payer: Kaiser Permanente Commercial	$791.10
Rate for Payer: MDX Hawaii PPO	$852.63

42999 Throat, adenoids, or tonsils procedure

Facility

$1,572.00

Service Code	HCPCS 42999
Hospital Charge Code	8729079
Hospital Revenue Code	450
Min. Negotiated Rate	$1,336.20
Max. Negotiated Rate	$1,524.84
Rate for Payer: Cash Price	$1,021.80
Rate for Payer: Health Management Network Commercial	$1,336.20
Rate for Payer: Kaiser Permanente Commercial	$1,414.80
Rate for Payer: MDX Hawaii PPO	$1,524.84

Know your out-of-pocket cost for care.

All Charges