Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

54700-I&D Epididymis/Testis/Scrotal Space

Facility

$9,042.00

Service Code	HCPCS 54700
Hospital Charge Code	8080058
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,770.74
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$4,521.00
Rate for Payer: Cash Price	$5,877.30
Rate for Payer: Cash Price	$5,877.30
Rate for Payer: Devoted Health Medicare	$4,973.10
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	$4,521.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$8,589.90
Rate for Payer: Health Management Network Commercial	$7,685.70
Rate for Payer: Humana Medicare	$4,521.00
Rate for Payer: Kaiser Permanente Commercial	$8,137.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,521.00
Rate for Payer: MDX Hawaii PPO	$8,770.74
Rate for Payer: Ohana Health Plan Medicaid	$4,521.00
Rate for Payer: Ohana Health Plan Medicare	$4,521.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,521.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

55040 Excision of hydrocele; unilateral

Professional

Both

$4,983.00

Service Code	HCPCS 55040
Hospital Charge Code	8039814
Hospital Revenue Code	975
Min. Negotiated Rate	$320.59
Max. Negotiated Rate	$4,235.55
Rate for Payer: AlohaCare Medicaid	$349.77
Rate for Payer: AlohaCare Medicare	$320.59
Rate for Payer: Cash Price	$3,238.95
Rate for Payer: Cash Price	$3,238.95
Rate for Payer: Devoted Health Medicare	$352.65
Rate for Payer: Hawaii Medical Service Association Medicare	$320.59
Rate for Payer: Hawaii Western Management Group Commercial	$386.62
Rate for Payer: Health Management Network Commercial	$4,235.55
Rate for Payer: Kaiser Permanente Commercial	$352.65
Rate for Payer: Kaiser Permanente Medicaid	$352.65
Rate for Payer: Kaiser Permanente Medicare	$352.65
Rate for Payer: Ohana Health Plan Medicaid	$349.77
Rate for Payer: Ohana Health Plan Medicare	$320.59
Rate for Payer: UnitedHealthcare Medicaid	$349.77
Rate for Payer: UnitedHealthcare Medicare	$320.59
Rate for Payer: University Health Alliance Commercial	$453.99

55100 Drainage of scrotal wall abscess

Professional

Both

$2,299.00

Service Code	HCPCS 55100
Hospital Charge Code	8039817
Hospital Revenue Code	975
Min. Negotiated Rate	$47.58
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$174.72
Rate for Payer: AlohaCare Medicare	$168.45
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$185.29
Rate for Payer: Hawaii Medical Service Association ABD	$174.72
Rate for Payer: Hawaii Medical Service Association Commercial	$286.50
Rate for Payer: Hawaii Medical Service Association Medicare	$168.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$174.72
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$185.29
Rate for Payer: Kaiser Permanente Medicaid	$185.29
Rate for Payer: Kaiser Permanente Medicare	$185.29
Rate for Payer: Ohana Health Plan Medicaid	$174.72
Rate for Payer: Ohana Health Plan Medicare	$168.45
Rate for Payer: UnitedHealthcare Medicaid	$174.72
Rate for Payer: UnitedHealthcare Medicare	$168.45
Rate for Payer: University Health Alliance Commercial	$269.00

55100-Drainage Scrotal Wall Abscess

Facility

$4,163.00

Service Code	HCPCS 55100
Hospital Charge Code	8080060
Hospital Revenue Code	450
Min. Negotiated Rate	$3,538.55
Max. Negotiated Rate	$4,038.11
Rate for Payer: Cash Price	$2,705.95
Rate for Payer: Health Management Network Commercial	$3,538.55
Rate for Payer: Kaiser Permanente Commercial	$3,746.70
Rate for Payer: MDX Hawaii PPO	$4,038.11

55100-Drainage Scrotal Wall Abscess

Facility

$4,163.00

Service Code	HCPCS 55100
Hospital Charge Code	8080060
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$4,038.11
Rate for Payer: AlohaCare Medicaid	$672.48
Rate for Payer: AlohaCare Medicare	$2,081.50
Rate for Payer: Cash Price	$2,705.95
Rate for Payer: Cash Price	$2,705.95
Rate for Payer: Devoted Health Medicare	$2,289.65
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	$2,081.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,954.85
Rate for Payer: Health Management Network Commercial	$3,538.55
Rate for Payer: Humana Medicare	$2,081.50
Rate for Payer: Kaiser Permanente Commercial	$3,746.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,081.50
Rate for Payer: MDX Hawaii PPO	$4,038.11
Rate for Payer: Ohana Health Plan Medicaid	$2,081.50
Rate for Payer: Ohana Health Plan Medicare	$2,081.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,081.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

55120-Scrotum

Facility

$9,042.00

Service Code	HCPCS 55120
Hospital Charge Code	8080151
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,770.74
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$4,521.00
Rate for Payer: Cash Price	$5,877.30
Rate for Payer: Cash Price	$5,877.30
Rate for Payer: Devoted Health Medicare	$4,973.10
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7,085.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,521.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Hawaii Western Management Group Commercial	$8,589.90
Rate for Payer: Health Management Network Commercial	$7,685.70
Rate for Payer: Humana Medicare	$4,521.00
Rate for Payer: Kaiser Permanente Commercial	$8,137.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,521.00
Rate for Payer: MDX Hawaii PPO	$8,770.74
Rate for Payer: Ohana Health Plan Medicaid	$4,521.00
Rate for Payer: Ohana Health Plan Medicare	$4,521.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,521.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

55120-Scrotum

Facility

$9,042.00

Service Code	HCPCS 55120
Hospital Charge Code	8080151
Hospital Revenue Code	450
Min. Negotiated Rate	$7,685.70
Max. Negotiated Rate	$8,770.74
Rate for Payer: Cash Price	$5,877.30
Rate for Payer: Health Management Network Commercial	$7,685.70
Rate for Payer: Kaiser Permanente Commercial	$8,137.80
Rate for Payer: MDX Hawaii PPO	$8,770.74

55250 Vasectomy, unilateral or bilateral, including postoperative semen examination(s)

Professional

Both

$1,201.00

Service Code	HCPCS 55250
Hospital Charge Code	8039822
Hospital Revenue Code	975
Min. Negotiated Rate	$225.11
Max. Negotiated Rate	$1,020.85
Rate for Payer: AlohaCare Medicaid	$240.51
Rate for Payer: AlohaCare Medicare	$225.11
Rate for Payer: Cash Price	$780.65
Rate for Payer: Cash Price	$780.65
Rate for Payer: Devoted Health Medicare	$247.62
Rate for Payer: Hawaii Medical Service Association ABD	$240.51
Rate for Payer: Hawaii Medical Service Association Commercial	$391.89
Rate for Payer: Hawaii Medical Service Association Medicare	$225.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$240.51
Rate for Payer: Hawaii Western Management Group Commercial	$286.00
Rate for Payer: Health Management Network Commercial	$1,020.85
Rate for Payer: Kaiser Permanente Commercial	$247.62
Rate for Payer: Kaiser Permanente Medicaid	$247.62
Rate for Payer: Kaiser Permanente Medicare	$247.62
Rate for Payer: Ohana Health Plan Medicaid	$240.51
Rate for Payer: Ohana Health Plan Medicare	$225.11
Rate for Payer: UnitedHealthcare Medicaid	$240.51
Rate for Payer: UnitedHealthcare Medicare	$225.11
Rate for Payer: University Health Alliance Commercial	$510.87

55559 LAPARO PROC, SPERMATIC CORD

Professional

Both

$1,180.00

Service Code	HCPCS 55559
Hospital Charge Code	9902266
Hospital Revenue Code	975
Min. Negotiated Rate	$1,003.00
Max. Negotiated Rate	$1,003.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Health Management Network Commercial	$1,003.00

55559 UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD ProFee

Professional

Both

$8,414.00

Service Code	HCPCS 55559
Hospital Charge Code	8020901
Hospital Revenue Code	963
Min. Negotiated Rate	$7,151.90
Max. Negotiated Rate	$7,151.90
Rate for Payer: Cash Price	$5,469.10
Rate for Payer: Health Management Network Commercial	$7,151.90

5.5MM ELITE ACROMIOBLASTER BURR

Facility

$268.00

Hospital Charge Code	8336061
Hospital Revenue Code	272
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$174.20
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$241.20
Rate for Payer: MDX Hawaii PPO	$259.96

5.5MM ELITE ACROMIOBLASTER BURR

Facility

$268.00

Hospital Charge Code	8336061
Hospital Revenue Code	272
Min. Negotiated Rate	$134.00
Max. Negotiated Rate	$259.96
Rate for Payer: AlohaCare Medicaid	$134.00
Rate for Payer: AlohaCare Medicare	$134.00
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$147.40
Rate for Payer: Hawaii Medical Service Association Medicare	$134.00
Rate for Payer: Hawaii Western Management Group Commercial	$254.60
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$134.00
Rate for Payer: Kaiser Permanente Commercial	$241.20
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: Kaiser Permanente Medicare	$134.00
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$134.00
Rate for Payer: Ohana Health Plan Medicare	$134.00
Rate for Payer: UnitedHealthcare Medicare	$134.00
Rate for Payer: University Health Alliance Commercial	$195.35

56405-I&D Vulva/Perineal Abscess

Facility

$1,106.00

Service Code	HCPCS 56405
Hospital Charge Code	8080062
Hospital Revenue Code	450
Min. Negotiated Rate	$940.10
Max. Negotiated Rate	$1,072.82
Rate for Payer: Cash Price	$718.90
Rate for Payer: Health Management Network Commercial	$940.10
Rate for Payer: Kaiser Permanente Commercial	$995.40
Rate for Payer: MDX Hawaii PPO	$1,072.82

56405-I&D Vulva/Perineal Abscess

Facility

$1,106.00

Service Code	HCPCS 56405
Hospital Charge Code	8080062
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	$553.00
Rate for Payer: Cash Price	$718.90
Rate for Payer: Cash Price	$718.90
Rate for Payer: Cash Price	$718.90
Rate for Payer: Devoted Health Medicare	$608.30
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	$553.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,050.70
Rate for Payer: Health Management Network Commercial	$940.10
Rate for Payer: Humana Medicare	$553.00
Rate for Payer: Kaiser Permanente Commercial	$995.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$553.00
Rate for Payer: MDX Hawaii PPO	$1,072.82
Rate for Payer: Ohana Health Plan Medicaid	$553.00
Rate for Payer: Ohana Health Plan Medicare	$553.00
Rate for Payer: UnitedHealthcare Medicare	$553.00
Rate for Payer: University Health Alliance Commercial	$806.16

56405 I&D VULVA/PERINEAL ABSCESS TechFee

Facility

$1,245.00

Service Code	HCPCS 56405
Hospital Charge Code	8211339
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	$622.50
Rate for Payer: Cash Price	$809.25
Rate for Payer: Cash Price	$809.25
Rate for Payer: Cash Price	$809.25
Rate for Payer: Devoted Health Medicare	$684.75
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	$622.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,182.75
Rate for Payer: Health Management Network Commercial	$1,058.25
Rate for Payer: Humana Medicare	$622.50
Rate for Payer: Kaiser Permanente Commercial	$1,120.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$622.50
Rate for Payer: MDX Hawaii PPO	$1,207.65
Rate for Payer: Ohana Health Plan Medicaid	$622.50
Rate for Payer: Ohana Health Plan Medicare	$622.50
Rate for Payer: UnitedHealthcare Medicare	$622.50
Rate for Payer: University Health Alliance Commercial	$907.48

56405 I&D VULVA/PERINEAL ABSCESS TechFee

Facility

$1,245.00

Service Code	HCPCS 56405
Hospital Charge Code	8211339
Hospital Revenue Code	450
Min. Negotiated Rate	$1,058.25
Max. Negotiated Rate	$1,207.65
Rate for Payer: Cash Price	$809.25
Rate for Payer: Health Management Network Commercial	$1,058.25
Rate for Payer: Kaiser Permanente Commercial	$1,120.50
Rate for Payer: MDX Hawaii PPO	$1,207.65

56420-I&D Bartholin Abscess

Facility

$1,170.00

Service Code	HCPCS 56420
Hospital Charge Code	8080064
Hospital Revenue Code	450
Min. Negotiated Rate	$994.50
Max. Negotiated Rate	$1,134.90
Rate for Payer: Cash Price	$760.50
Rate for Payer: Health Management Network Commercial	$994.50
Rate for Payer: Kaiser Permanente Commercial	$1,053.00
Rate for Payer: MDX Hawaii PPO	$1,134.90

56420-I&D Bartholin Abscess

Facility

$1,170.00

Service Code	HCPCS 56420
Hospital Charge Code	8080064
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	$585.00
Rate for Payer: Cash Price	$760.50
Rate for Payer: Cash Price	$760.50
Rate for Payer: Cash Price	$760.50
Rate for Payer: Devoted Health Medicare	$643.50
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	$585.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,111.50
Rate for Payer: Health Management Network Commercial	$994.50
Rate for Payer: Humana Medicare	$585.00
Rate for Payer: Kaiser Permanente Commercial	$1,053.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$585.00
Rate for Payer: MDX Hawaii PPO	$1,134.90
Rate for Payer: Ohana Health Plan Medicaid	$585.00
Rate for Payer: Ohana Health Plan Medicare	$585.00
Rate for Payer: UnitedHealthcare Medicare	$585.00
Rate for Payer: University Health Alliance Commercial	$852.81

56420 I&D OF BARTHOLINS GLAND ABSCESS TechFee

Facility

$1,312.00

Service Code	HCPCS 56420
Hospital Charge Code	8211340
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	$656.00
Rate for Payer: Cash Price	$852.80
Rate for Payer: Cash Price	$852.80
Rate for Payer: Cash Price	$852.80
Rate for Payer: Devoted Health Medicare	$721.60
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	$656.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,246.40
Rate for Payer: Health Management Network Commercial	$1,115.20
Rate for Payer: Humana Medicare	$656.00
Rate for Payer: Kaiser Permanente Commercial	$1,180.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$656.00
Rate for Payer: MDX Hawaii PPO	$1,272.64
Rate for Payer: Ohana Health Plan Medicaid	$656.00
Rate for Payer: Ohana Health Plan Medicare	$656.00
Rate for Payer: UnitedHealthcare Medicare	$656.00
Rate for Payer: University Health Alliance Commercial	$956.32

56420 I&D OF BARTHOLINS GLAND ABSCESS TechFee

Facility

$1,312.00

Service Code	HCPCS 56420
Hospital Charge Code	8211340
Hospital Revenue Code	450
Min. Negotiated Rate	$1,115.20
Max. Negotiated Rate	$1,272.64
Rate for Payer: Cash Price	$852.80
Rate for Payer: Health Management Network Commercial	$1,115.20
Rate for Payer: Kaiser Permanente Commercial	$1,180.80
Rate for Payer: MDX Hawaii PPO	$1,272.64

56501 Destruction of lesion(s), vulva; simple

Professional

Both

$2,872.00

Service Code	HCPCS 56501
Hospital Charge Code	8039842
Hospital Revenue Code	975
Min. Negotiated Rate	$93.34
Max. Negotiated Rate	$2,441.20
Rate for Payer: AlohaCare Medicaid	$142.37
Rate for Payer: AlohaCare Medicare	$124.63
Rate for Payer: Cash Price	$1,866.80
Rate for Payer: Cash Price	$1,866.80
Rate for Payer: Devoted Health Medicare	$137.09
Rate for Payer: Hawaii Medical Service Association ABD	$142.37
Rate for Payer: Hawaii Medical Service Association Medicare	$124.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$142.37
Rate for Payer: Hawaii Western Management Group Commercial	$93.34
Rate for Payer: Health Management Network Commercial	$2,441.20
Rate for Payer: Kaiser Permanente Commercial	$137.09
Rate for Payer: Kaiser Permanente Medicaid	$137.09
Rate for Payer: Kaiser Permanente Medicare	$137.09
Rate for Payer: Ohana Health Plan Medicaid	$142.37
Rate for Payer: Ohana Health Plan Medicare	$124.63
Rate for Payer: UnitedHealthcare Medicaid	$142.37
Rate for Payer: UnitedHealthcare Medicare	$124.63

57061 Destruction of vaginal lesion(s); simple

Professional

Both

$4,505.00

Service Code	HCPCS 57061
Hospital Charge Code	8039858
Hospital Revenue Code	975
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$3,829.25
Rate for Payer: AlohaCare Medicaid	$123.11
Rate for Payer: AlohaCare Medicare	$110.10
Rate for Payer: Cash Price	$2,928.25
Rate for Payer: Cash Price	$2,928.25
Rate for Payer: Devoted Health Medicare	$121.11
Rate for Payer: Hawaii Medical Service Association ABD	$123.11
Rate for Payer: Hawaii Medical Service Association Medicare	$110.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.11
Rate for Payer: Hawaii Western Management Group Commercial	$93.60
Rate for Payer: Health Management Network Commercial	$3,829.25
Rate for Payer: Kaiser Permanente Commercial	$121.11
Rate for Payer: Kaiser Permanente Medicaid	$121.11
Rate for Payer: Kaiser Permanente Medicare	$121.11
Rate for Payer: Ohana Health Plan Medicaid	$123.11
Rate for Payer: Ohana Health Plan Medicare	$110.10
Rate for Payer: UnitedHealthcare Medicaid	$123.11
Rate for Payer: UnitedHealthcare Medicare	$110.10
Rate for Payer: University Health Alliance Commercial	$160.39

57170 Diaphragm or cervical cap fitting with instructions

Professional

Both

$281.00

Service Code	HCPCS 57170
Hospital Charge Code	8039867
Hospital Revenue Code	975
Min. Negotiated Rate	$40.04
Max. Negotiated Rate	$238.85
Rate for Payer: AlohaCare Medicaid	$46.48
Rate for Payer: AlohaCare Medicare	$40.04
Rate for Payer: Cash Price	$182.65
Rate for Payer: Cash Price	$182.65
Rate for Payer: Devoted Health Medicare	$44.04
Rate for Payer: Hawaii Medical Service Association ABD	$46.48
Rate for Payer: Hawaii Medical Service Association Commercial	$78.88
Rate for Payer: Hawaii Medical Service Association Medicare	$40.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.48
Rate for Payer: Hawaii Western Management Group Commercial	$55.12
Rate for Payer: Health Management Network Commercial	$238.85
Rate for Payer: Kaiser Permanente Commercial	$44.04
Rate for Payer: Kaiser Permanente Medicaid	$44.04
Rate for Payer: Kaiser Permanente Medicare	$44.04
Rate for Payer: Ohana Health Plan Medicaid	$46.48
Rate for Payer: Ohana Health Plan Medicare	$40.04
Rate for Payer: UnitedHealthcare Medicaid	$46.48
Rate for Payer: UnitedHealthcare Medicare	$40.04
Rate for Payer: University Health Alliance Commercial	$62.13

57170 DIAPHRAGM OR CERVICAL CAP FITTING WITH INSTRUCTIONS ProFee

Professional

Both

$281.00

Service Code	HCPCS 57170
Hospital Charge Code	8020979
Hospital Revenue Code	975
Min. Negotiated Rate	$40.04
Max. Negotiated Rate	$238.85
Rate for Payer: AlohaCare Medicaid	$46.48
Rate for Payer: AlohaCare Medicare	$40.04
Rate for Payer: Cash Price	$182.65
Rate for Payer: Cash Price	$182.65
Rate for Payer: Devoted Health Medicare	$44.04
Rate for Payer: Hawaii Medical Service Association ABD	$46.48
Rate for Payer: Hawaii Medical Service Association Commercial	$78.88
Rate for Payer: Hawaii Medical Service Association Medicare	$40.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.48
Rate for Payer: Hawaii Western Management Group Commercial	$55.12
Rate for Payer: Health Management Network Commercial	$238.85
Rate for Payer: Kaiser Permanente Commercial	$44.04
Rate for Payer: Kaiser Permanente Medicaid	$44.04
Rate for Payer: Kaiser Permanente Medicare	$44.04
Rate for Payer: Ohana Health Plan Medicaid	$46.48
Rate for Payer: Ohana Health Plan Medicare	$40.04
Rate for Payer: UnitedHealthcare Medicaid	$46.48
Rate for Payer: UnitedHealthcare Medicare	$40.04
Rate for Payer: University Health Alliance Commercial	$62.13

57200 COLPORRHAPHY SUTURE INJURY VAGINA TechFee

Facility

$9,886.00

Service Code	HCPCS 57200
Hospital Charge Code	8218188
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,589.42
Rate for Payer: AlohaCare Medicaid	$672.48
Rate for Payer: AlohaCare Medicare	$4,943.00
Rate for Payer: Cash Price	$6,425.90
Rate for Payer: Cash Price	$6,425.90
Rate for Payer: Devoted Health Medicare	$5,437.30
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	$4,943.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$9,391.70
Rate for Payer: Health Management Network Commercial	$8,403.10
Rate for Payer: Humana Medicare	$4,943.00
Rate for Payer: Kaiser Permanente Commercial	$8,897.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,943.00
Rate for Payer: MDX Hawaii PPO	$9,589.42
Rate for Payer: Ohana Health Plan Medicaid	$4,943.00
Rate for Payer: Ohana Health Plan Medicare	$4,943.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,943.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges