Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

76770 US Retroperitoneal Complete

Facility

$858.00

Service Code	HCPCS 76770
Hospital Charge Code	8280902
Hospital Revenue Code	402
Min. Negotiated Rate	$729.30
Max. Negotiated Rate	$832.26
Rate for Payer: Cash Price	$557.70
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: Kaiser Permanente Commercial	$772.20
Rate for Payer: MDX Hawaii PPO	$832.26

76775 US Retroperitoneal Limited

Facility

$808.00

Service Code	HCPCS 76775
Hospital Charge Code	8280905
Hospital Revenue Code	402
Min. Negotiated Rate	$686.80
Max. Negotiated Rate	$783.76
Rate for Payer: Cash Price	$525.20
Rate for Payer: Health Management Network Commercial	$686.80
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: MDX Hawaii PPO	$783.76

76775 US Retroperitoneal Limited

Facility

$808.00

Service Code	HCPCS 76775
Hospital Charge Code	8280905
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$783.76
Rate for Payer: AlohaCare Medicaid	$404.00
Rate for Payer: AlohaCare Medicare	$404.00
Rate for Payer: Cash Price	$525.20
Rate for Payer: Cash Price	$525.20
Rate for Payer: Devoted Health Medicare	$444.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$404.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$686.80
Rate for Payer: Humana Medicare	$404.00
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: Kaiser Permanente Medicaid	$412.08
Rate for Payer: Kaiser Permanente Medicare	$404.00
Rate for Payer: MDX Hawaii PPO	$783.76
Rate for Payer: Ohana Health Plan Medicaid	$404.00
Rate for Payer: Ohana Health Plan Medicare	$404.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$404.00
Rate for Payer: University Health Alliance Commercial	$202.63

76802 US PG UTER F&MAT 14 WK TABDL EA GESTATION ProFee

Professional

Both

$115.00

Service Code	HCPCS 76802 26
Hospital Charge Code	8102971
Hospital Revenue Code	972
Min. Negotiated Rate	$38.48
Max. Negotiated Rate	$97.75
Rate for Payer: AlohaCare Medicaid	$38.48
Rate for Payer: AlohaCare Medicare	$40.36
Rate for Payer: Cash Price	$74.75
Rate for Payer: Cash Price	$74.75
Rate for Payer: Devoted Health Medicare	$44.40
Rate for Payer: Hawaii Medical Service Association Medicare	$40.36
Rate for Payer: Hawaii Western Management Group Commercial	$71.92
Rate for Payer: Health Management Network Commercial	$97.75
Rate for Payer: Kaiser Permanente Commercial	$44.40
Rate for Payer: Kaiser Permanente Medicaid	$44.40
Rate for Payer: Kaiser Permanente Medicare	$44.40
Rate for Payer: Ohana Health Plan Medicaid	$38.48
Rate for Payer: Ohana Health Plan Medicare	$40.36
Rate for Payer: UnitedHealthcare Medicaid	$38.48
Rate for Payer: UnitedHealthcare Medicare	$40.36

76810 ñ US OB Fetal/Maternal Eval, => 14 Weeks ìEa Addtl Gestationî

Professional

Both

$183.00

Service Code	HCPCS 76810
Hospital Charge Code	9551882
Hospital Revenue Code	972
Min. Negotiated Rate	$56.86
Max. Negotiated Rate	$292.28
Rate for Payer: AlohaCare Medicaid	$56.86
Rate for Payer: AlohaCare Medicare	$95.13
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cash Price	$118.95
Rate for Payer: Devoted Health Medicare	$104.64
Rate for Payer: Hawaii Medical Service Association Medicare	$95.13
Rate for Payer: Hawaii Western Management Group Commercial	$292.28
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$104.64
Rate for Payer: Kaiser Permanente Medicaid	$104.64
Rate for Payer: Kaiser Permanente Medicare	$104.64
Rate for Payer: Ohana Health Plan Medicaid	$56.86
Rate for Payer: Ohana Health Plan Medicare	$95.13
Rate for Payer: UnitedHealthcare Medicaid	$56.86
Rate for Payer: UnitedHealthcare Medicare	$95.13

76810 US OB >14 WKS,EA ADD GEST:PROF

Professional

Both

$178.00

Service Code	HCPCS 76810 26
Hospital Charge Code	9930279
Hospital Revenue Code	972
Min. Negotiated Rate	$48.22
Max. Negotiated Rate	$292.28
Rate for Payer: AlohaCare Medicaid	$56.86
Rate for Payer: AlohaCare Medicare	$48.22
Rate for Payer: Cash Price	$115.70
Rate for Payer: Cash Price	$115.70
Rate for Payer: Devoted Health Medicare	$53.04
Rate for Payer: Hawaii Medical Service Association Medicare	$48.22
Rate for Payer: Hawaii Western Management Group Commercial	$292.28
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Kaiser Permanente Commercial	$53.04
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$53.04
Rate for Payer: Ohana Health Plan Medicaid	$56.86
Rate for Payer: Ohana Health Plan Medicare	$48.22
Rate for Payer: UnitedHealthcare Medicaid	$56.86
Rate for Payer: UnitedHealthcare Medicare	$48.22

76810 US PG UTER F&MAT AFTER 1ST TRI ABDL EA GESTATION ProFee

Professional

Both

$178.00

Service Code	HCPCS 76810 26
Hospital Charge Code	8102973
Hospital Revenue Code	972
Min. Negotiated Rate	$48.22
Max. Negotiated Rate	$292.28
Rate for Payer: AlohaCare Medicaid	$56.86
Rate for Payer: AlohaCare Medicare	$48.22
Rate for Payer: Cash Price	$115.70
Rate for Payer: Cash Price	$115.70
Rate for Payer: Devoted Health Medicare	$53.04
Rate for Payer: Hawaii Medical Service Association Medicare	$48.22
Rate for Payer: Hawaii Western Management Group Commercial	$292.28
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Kaiser Permanente Commercial	$53.04
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$53.04
Rate for Payer: Ohana Health Plan Medicaid	$56.86
Rate for Payer: Ohana Health Plan Medicare	$48.22
Rate for Payer: UnitedHealthcare Medicaid	$56.86
Rate for Payer: UnitedHealthcare Medicare	$48.22

76811 ñ US OB Fetal/Maternal Eval w/Detailed Fetal Anatomic Exam

Facility

$1,275.00

Service Code	HCPCS 76811
Hospital Charge Code	9236479
Hospital Revenue Code	320
Min. Negotiated Rate	$112.44
Max. Negotiated Rate	$1,236.75
Rate for Payer: AlohaCare Medicaid	$637.50
Rate for Payer: AlohaCare Medicare	$637.50
Rate for Payer: Cash Price	$828.75
Rate for Payer: Cash Price	$828.75
Rate for Payer: Devoted Health Medicare	$701.25
Rate for Payer: Hawaii Medical Service Association ABD	$112.44
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$637.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$131.50
Rate for Payer: Hawaii Western Management Group Commercial	$243.77
Rate for Payer: Health Management Network Commercial	$1,083.75
Rate for Payer: Humana Medicare	$637.50
Rate for Payer: Kaiser Permanente Commercial	$1,147.50
Rate for Payer: Kaiser Permanente Medicaid	$650.25
Rate for Payer: Kaiser Permanente Medicare	$637.50
Rate for Payer: MDX Hawaii PPO	$1,236.75
Rate for Payer: Ohana Health Plan Medicaid	$637.50
Rate for Payer: Ohana Health Plan Medicare	$637.50
Rate for Payer: UnitedHealthcare Medicaid	$112.44
Rate for Payer: UnitedHealthcare Medicare	$637.50
Rate for Payer: University Health Alliance Commercial	$436.01

76811 ñ US OB Fetal/Maternal Eval w/Detailed Fetal Anatomic Exam

Professional

Both

$332.00

Service Code	HCPCS 76811
Hospital Charge Code	9236479
Hospital Revenue Code	972
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$115.61
Rate for Payer: AlohaCare Medicare	$196.46
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$216.11
Rate for Payer: Hawaii Medical Service Association Medicare	$196.46
Rate for Payer: Hawaii Western Management Group Commercial	$243.15
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$216.11
Rate for Payer: Kaiser Permanente Medicaid	$216.11
Rate for Payer: Kaiser Permanente Medicare	$216.11
Rate for Payer: Ohana Health Plan Medicaid	$115.61
Rate for Payer: Ohana Health Plan Medicare	$196.46
Rate for Payer: UnitedHealthcare Medicaid	$115.61
Rate for Payer: UnitedHealthcare Medicare	$196.46

76811 ñ US OB Fetal/Maternal Eval w/Detailed Fetal Anatomic Exam

Facility

$1,275.00

Service Code	HCPCS 76811
Hospital Charge Code	9236479
Hospital Revenue Code	320
Min. Negotiated Rate	$1,083.75
Max. Negotiated Rate	$1,236.75
Rate for Payer: Cash Price	$828.75
Rate for Payer: Health Management Network Commercial	$1,083.75
Rate for Payer: Kaiser Permanente Commercial	$1,147.50
Rate for Payer: MDX Hawaii PPO	$1,236.75

76815 US OB Limited

Facility

$808.00

Service Code	HCPCS 76815
Hospital Charge Code	8280906
Hospital Revenue Code	402
Min. Negotiated Rate	$686.80
Max. Negotiated Rate	$783.76
Rate for Payer: Cash Price	$525.20
Rate for Payer: Health Management Network Commercial	$686.80
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: MDX Hawaii PPO	$783.76

76815 US OB Limited

Facility

$808.00

Service Code	HCPCS 76815
Hospital Charge Code	8280906
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$783.76
Rate for Payer: AlohaCare Medicaid	$404.00
Rate for Payer: AlohaCare Medicare	$404.00
Rate for Payer: Cash Price	$525.20
Rate for Payer: Cash Price	$525.20
Rate for Payer: Devoted Health Medicare	$444.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$404.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$686.80
Rate for Payer: Humana Medicare	$404.00
Rate for Payer: Kaiser Permanente Commercial	$727.20
Rate for Payer: Kaiser Permanente Medicaid	$412.08
Rate for Payer: Kaiser Permanente Medicare	$404.00
Rate for Payer: MDX Hawaii PPO	$783.76
Rate for Payer: Ohana Health Plan Medicaid	$404.00
Rate for Payer: Ohana Health Plan Medicare	$404.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$404.00
Rate for Payer: University Health Alliance Commercial	$183.63

76815 US OB LIMITED CHARGE

Facility

$728.00

Service Code	HCPCS 76815
Hospital Charge Code	8280915
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$706.16
Rate for Payer: AlohaCare Medicaid	$364.00
Rate for Payer: AlohaCare Medicare	$364.00
Rate for Payer: Cash Price	$473.20
Rate for Payer: Cash Price	$473.20
Rate for Payer: Devoted Health Medicare	$400.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$364.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$618.80
Rate for Payer: Humana Medicare	$364.00
Rate for Payer: Kaiser Permanente Commercial	$655.20
Rate for Payer: Kaiser Permanente Medicaid	$371.28
Rate for Payer: Kaiser Permanente Medicare	$364.00
Rate for Payer: MDX Hawaii PPO	$706.16
Rate for Payer: Ohana Health Plan Medicaid	$364.00
Rate for Payer: Ohana Health Plan Medicare	$364.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$364.00
Rate for Payer: University Health Alliance Commercial	$183.63

76815 US OB LIMITED CHARGE

Facility

$728.00

Service Code	HCPCS 76815
Hospital Charge Code	8280915
Hospital Revenue Code	402
Min. Negotiated Rate	$618.80
Max. Negotiated Rate	$706.16
Rate for Payer: Cash Price	$473.20
Rate for Payer: Health Management Network Commercial	$618.80
Rate for Payer: Kaiser Permanente Commercial	$655.20
Rate for Payer: MDX Hawaii PPO	$706.16

76815 US OB Limited POC

Facility

$230.00

Service Code	HCPCS 76815
Hospital Charge Code	8041470
Hospital Revenue Code	521
Min. Negotiated Rate	$195.50
Max. Negotiated Rate	$223.10
Rate for Payer: Cash Price	$149.50
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: MDX Hawaii PPO	$223.10

76815 US OB Limited POC

Facility

$230.00

Service Code	HCPCS 76815
Hospital Charge Code	8041470
Hospital Revenue Code	521
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$223.10
Rate for Payer: AlohaCare Medicaid	$115.00
Rate for Payer: AlohaCare Medicare	$115.00
Rate for Payer: Cash Price	$149.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$126.50
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$115.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Humana Medicare	$115.00
Rate for Payer: Kaiser Permanente Commercial	$207.00
Rate for Payer: Kaiser Permanente Medicaid	$117.30
Rate for Payer: Kaiser Permanente Medicare	$115.00
Rate for Payer: MDX Hawaii PPO	$223.10
Rate for Payer: Ohana Health Plan Medicaid	$115.00
Rate for Payer: Ohana Health Plan Medicare	$115.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$115.00
Rate for Payer: University Health Alliance Commercial	$183.63

76815 US OB LIMITED ProFee

Professional

Both

$145.00

Service Code	HCPCS 76815
Hospital Charge Code	8022161
Hospital Revenue Code	972
Min. Negotiated Rate	$53.36
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$53.36
Rate for Payer: AlohaCare Medicare	$88.85
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$97.73
Rate for Payer: Hawaii Medical Service Association Medicare	$88.85
Rate for Payer: Hawaii Western Management Group Commercial	$98.47
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$97.73
Rate for Payer: Kaiser Permanente Medicaid	$97.73
Rate for Payer: Kaiser Permanente Medicare	$97.73
Rate for Payer: Ohana Health Plan Medicaid	$53.36
Rate for Payer: Ohana Health Plan Medicare	$88.85
Rate for Payer: UnitedHealthcare Medicaid	$53.36
Rate for Payer: UnitedHealthcare Medicare	$88.85

76816 US OB FOLLOW UP CHARGE

Facility

$588.00

Service Code	HCPCS 76816
Hospital Charge Code	8280912
Hospital Revenue Code	402
Min. Negotiated Rate	$36.81
Max. Negotiated Rate	$570.36
Rate for Payer: AlohaCare Medicaid	$294.00
Rate for Payer: AlohaCare Medicare	$294.00
Rate for Payer: Cash Price	$382.20
Rate for Payer: Cash Price	$382.20
Rate for Payer: Devoted Health Medicare	$323.40
Rate for Payer: Hawaii Medical Service Association ABD	$36.81
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$294.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$39.59
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$499.80
Rate for Payer: Humana Medicare	$294.00
Rate for Payer: Kaiser Permanente Commercial	$529.20
Rate for Payer: Kaiser Permanente Medicaid	$299.88
Rate for Payer: Kaiser Permanente Medicare	$294.00
Rate for Payer: MDX Hawaii PPO	$570.36
Rate for Payer: Ohana Health Plan Medicaid	$294.00
Rate for Payer: Ohana Health Plan Medicare	$294.00
Rate for Payer: UnitedHealthcare Medicaid	$36.81
Rate for Payer: UnitedHealthcare Medicare	$294.00
Rate for Payer: University Health Alliance Commercial	$203.81

76816 US OB FOLLOW UP CHARGE

Facility

$588.00

Service Code	HCPCS 76816
Hospital Charge Code	8280912
Hospital Revenue Code	402
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$570.36
Rate for Payer: Cash Price	$382.20
Rate for Payer: Health Management Network Commercial	$499.80
Rate for Payer: Kaiser Permanente Commercial	$529.20
Rate for Payer: MDX Hawaii PPO	$570.36

76816 US OB FOLLOW UP CHARGE

Professional

Both

$205.00

Service Code	HCPCS 76816
Hospital Charge Code	8280912
Hospital Revenue Code	972
Min. Negotiated Rate	$72.85
Max. Negotiated Rate	$174.25
Rate for Payer: AlohaCare Medicaid	$72.85
Rate for Payer: AlohaCare Medicare	$121.73
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$133.90
Rate for Payer: Hawaii Medical Service Association Medicare	$121.73
Rate for Payer: Hawaii Western Management Group Commercial	$80.34
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$133.90
Rate for Payer: Kaiser Permanente Medicaid	$133.90
Rate for Payer: Kaiser Permanente Medicare	$133.90
Rate for Payer: Ohana Health Plan Medicaid	$72.85
Rate for Payer: Ohana Health Plan Medicare	$121.73
Rate for Payer: UnitedHealthcare Medicaid	$72.85
Rate for Payer: UnitedHealthcare Medicare	$121.73

76816 US PG UTER R-T IMG F-UP TABDL APPR PR FETUS ProFee

Professional

Both

$155.00

Service Code	HCPCS 76816 26
Hospital Charge Code	8102979
Hospital Revenue Code	972
Min. Negotiated Rate	$41.79
Max. Negotiated Rate	$131.75
Rate for Payer: AlohaCare Medicaid	$72.85
Rate for Payer: AlohaCare Medicare	$41.79
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Devoted Health Medicare	$45.97
Rate for Payer: Hawaii Medical Service Association Medicare	$41.79
Rate for Payer: Hawaii Western Management Group Commercial	$80.34
Rate for Payer: Health Management Network Commercial	$131.75
Rate for Payer: Kaiser Permanente Commercial	$45.97
Rate for Payer: Kaiser Permanente Medicaid	$45.97
Rate for Payer: Kaiser Permanente Medicare	$45.97
Rate for Payer: Ohana Health Plan Medicaid	$72.85
Rate for Payer: Ohana Health Plan Medicare	$41.79
Rate for Payer: UnitedHealthcare Medicaid	$72.85
Rate for Payer: UnitedHealthcare Medicare	$41.79

76817 US OB Transvaginal

Facility

$858.00

Service Code	HCPCS 76817 26
Hospital Charge Code	9325764
Hospital Revenue Code	402
Min. Negotiated Rate	$46.06
Max. Negotiated Rate	$832.26
Rate for Payer: AlohaCare Medicaid	$429.00
Rate for Payer: AlohaCare Medicare	$429.00
Rate for Payer: Cash Price	$557.70
Rate for Payer: Cash Price	$557.70
Rate for Payer: Devoted Health Medicare	$471.90
Rate for Payer: Hawaii Medical Service Association ABD	$46.06
Rate for Payer: Hawaii Medical Service Association Medicare	$429.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$53.86
Rate for Payer: Hawaii Western Management Group Commercial	$815.10
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: Humana Medicare	$429.00
Rate for Payer: Kaiser Permanente Commercial	$772.20
Rate for Payer: Kaiser Permanente Medicaid	$437.58
Rate for Payer: Kaiser Permanente Medicare	$429.00
Rate for Payer: MDX Hawaii PPO	$832.26
Rate for Payer: Ohana Health Plan Medicaid	$429.00
Rate for Payer: Ohana Health Plan Medicare	$429.00
Rate for Payer: UnitedHealthcare Medicaid	$46.06
Rate for Payer: UnitedHealthcare Medicare	$429.00
Rate for Payer: University Health Alliance Commercial	$193.75

76817 US OB Transvaginal

Facility

$858.00

Service Code	HCPCS 76817 26
Hospital Charge Code	9325764
Hospital Revenue Code	402
Min. Negotiated Rate	$729.30
Max. Negotiated Rate	$832.26
Rate for Payer: Cash Price	$557.70
Rate for Payer: Health Management Network Commercial	$729.30
Rate for Payer: Kaiser Permanente Commercial	$772.20
Rate for Payer: MDX Hawaii PPO	$832.26

76817 US OB TRANSVAGINAL CHARGE

Facility

$778.00

Service Code	HCPCS 76817
Hospital Charge Code	8280922
Hospital Revenue Code	402
Min. Negotiated Rate	$46.06
Max. Negotiated Rate	$754.66
Rate for Payer: AlohaCare Medicaid	$389.00
Rate for Payer: AlohaCare Medicare	$389.00
Rate for Payer: Cash Price	$505.70
Rate for Payer: Cash Price	$505.70
Rate for Payer: Devoted Health Medicare	$427.90
Rate for Payer: Hawaii Medical Service Association ABD	$46.06
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$389.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$53.86
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$661.30
Rate for Payer: Humana Medicare	$389.00
Rate for Payer: Kaiser Permanente Commercial	$700.20
Rate for Payer: Kaiser Permanente Medicaid	$396.78
Rate for Payer: Kaiser Permanente Medicare	$389.00
Rate for Payer: MDX Hawaii PPO	$754.66
Rate for Payer: Ohana Health Plan Medicaid	$389.00
Rate for Payer: Ohana Health Plan Medicare	$389.00
Rate for Payer: UnitedHealthcare Medicaid	$46.06
Rate for Payer: UnitedHealthcare Medicare	$389.00
Rate for Payer: University Health Alliance Commercial	$193.75

76817 US OB TRANSVAGINAL CHARGE

Facility

$778.00

Service Code	HCPCS 76817
Hospital Charge Code	8280922
Hospital Revenue Code	402
Min. Negotiated Rate	$661.30
Max. Negotiated Rate	$754.66
Rate for Payer: Cash Price	$505.70
Rate for Payer: Health Management Network Commercial	$661.30
Rate for Payer: Kaiser Permanente Commercial	$700.20
Rate for Payer: MDX Hawaii PPO	$754.66

Know your out-of-pocket cost for care.

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