Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG SUTURE COMPLEX-EYEL+-2.6-7.5

Facility

$3,187.00

Service Code	HCPCS 13152
Hospital Charge Code	H4500718
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$1,593.50
Rate for Payer: AlohaCare Medicare	$2,868.30
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Devoted Health Medicare	$3,155.13
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,868.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.65
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Humana Medicare	$2,868.30
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39
Rate for Payer: Ohana Health Plan Medicaid	$2,868.30
Rate for Payer: Ohana Health Plan Medicare	$2,868.30
Rate for Payer: UnitedHealthcare Medicare	$2,868.30
Rate for Payer: University Health Alliance Commercial	$6,743.44

HCHG SUTURE COMPLEX-EYEL+-2.6-7.5

Facility

$3,187.00

Service Code	HCPCS 13152
Hospital Charge Code	H4500718
Hospital Revenue Code	450
Min. Negotiated Rate	$2,708.95
Max. Negotiated Rate	$3,091.39
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39

HCHG SUTURE COMPLEX-EYEL+-ADDL 5

Facility

$2,034.00

Service Code	HCPCS 13153
Hospital Charge Code	H4500720
Hospital Revenue Code	450
Min. Negotiated Rate	$1,728.90
Max. Negotiated Rate	$1,972.98
Rate for Payer: Cash Price	$1,322.10
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Kaiser Permanente Commercial	$1,830.60
Rate for Payer: MDX Hawaii PPO	$1,972.98

HCHG SUTURE COMPLEX-EYEL+-ADDL 5

Facility

$2,034.00

Service Code	HCPCS 13153
Hospital Charge Code	H4500720
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$2,013.66
Rate for Payer: AlohaCare Medicaid	$1,017.00
Rate for Payer: AlohaCare Medicare	$1,830.60
Rate for Payer: Cash Price	$1,322.10
Rate for Payer: Cash Price	$1,322.10
Rate for Payer: Devoted Health Medicare	$2,013.66
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,830.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.30
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Humana Medicare	$1,830.60
Rate for Payer: Kaiser Permanente Commercial	$1,830.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,830.60
Rate for Payer: MDX Hawaii PPO	$1,972.98
Rate for Payer: Ohana Health Plan Medicaid	$1,830.60
Rate for Payer: Ohana Health Plan Medicare	$1,830.60
Rate for Payer: UnitedHealthcare Medicare	$1,830.60
Rate for Payer: University Health Alliance Commercial	$1,482.58

HCHG SUTURE COMPLEX-FOREH+-1.1-2.5

Facility

$2,246.00

Service Code	HCPCS 13131
Hospital Charge Code	H4500722
Hospital Revenue Code	450
Min. Negotiated Rate	$1,909.10
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62

HCHG SUTURE COMPLEX-FOREH+-1.1-2.5

Facility

$2,246.00

Service Code	HCPCS 13131
Hospital Charge Code	H4500722
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$2,223.54
Rate for Payer: AlohaCare Medicaid	$1,123.00
Rate for Payer: AlohaCare Medicare	$2,021.40
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Devoted Health Medicare	$2,223.54
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,021.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,133.70
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Humana Medicare	$2,021.40
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62
Rate for Payer: Ohana Health Plan Medicaid	$2,021.40
Rate for Payer: Ohana Health Plan Medicare	$2,021.40
Rate for Payer: UnitedHealthcare Medicare	$2,021.40
Rate for Payer: University Health Alliance Commercial	$1,637.11

HCHG SUTURE COMPLEX-FOREH+-2.6-7.5

Facility

$3,187.00

Service Code	HCPCS 13132
Hospital Charge Code	H4500724
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$1,593.50
Rate for Payer: AlohaCare Medicare	$2,868.30
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Devoted Health Medicare	$3,155.13
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,868.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.65
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Humana Medicare	$2,868.30
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39
Rate for Payer: Ohana Health Plan Medicaid	$2,868.30
Rate for Payer: Ohana Health Plan Medicare	$2,868.30
Rate for Payer: UnitedHealthcare Medicare	$2,868.30
Rate for Payer: University Health Alliance Commercial	$10,679.55

HCHG SUTURE COMPLEX-FOREH+-2.6-7.5

Facility

$3,187.00

Service Code	HCPCS 13132
Hospital Charge Code	H4500724
Hospital Revenue Code	450
Min. Negotiated Rate	$2,708.95
Max. Negotiated Rate	$3,091.39
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39

HCHG SUTURE COMPLEX-FOREH+-ADDL 5

Facility

$692.00

Service Code	HCPCS 13133
Hospital Charge Code	H4500726
Hospital Revenue Code	450
Min. Negotiated Rate	$346.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$346.00
Rate for Payer: AlohaCare Medicare	$622.80
Rate for Payer: Cash Price	$449.80
Rate for Payer: Cash Price	$449.80
Rate for Payer: Devoted Health Medicare	$685.08
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$622.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$657.40
Rate for Payer: Health Management Network Commercial	$588.20
Rate for Payer: Humana Medicare	$622.80
Rate for Payer: Kaiser Permanente Commercial	$622.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$622.80
Rate for Payer: MDX Hawaii PPO	$671.24
Rate for Payer: Ohana Health Plan Medicaid	$622.80
Rate for Payer: Ohana Health Plan Medicare	$622.80
Rate for Payer: UnitedHealthcare Medicare	$622.80
Rate for Payer: University Health Alliance Commercial	$504.40

HCHG SUTURE COMPLEX-FOREH+-ADDL 5

Facility

$692.00

Service Code	HCPCS 13133
Hospital Charge Code	H4500726
Hospital Revenue Code	450
Min. Negotiated Rate	$588.20
Max. Negotiated Rate	$671.24
Rate for Payer: Cash Price	$449.80
Rate for Payer: Health Management Network Commercial	$588.20
Rate for Payer: Kaiser Permanente Commercial	$622.80
Rate for Payer: MDX Hawaii PPO	$671.24

HCHG SUTURE COMPLEX-SCALP+-1.1-2.5

Facility

$3,187.00

Service Code	HCPCS 13120
Hospital Charge Code	H4500728
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$3,155.13
Rate for Payer: AlohaCare Medicaid	$1,593.50
Rate for Payer: AlohaCare Medicare	$2,868.30
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Devoted Health Medicare	$3,155.13
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,868.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.65
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Humana Medicare	$2,868.30
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39
Rate for Payer: Ohana Health Plan Medicaid	$2,868.30
Rate for Payer: Ohana Health Plan Medicare	$2,868.30
Rate for Payer: UnitedHealthcare Medicare	$2,868.30
Rate for Payer: University Health Alliance Commercial	$2,323.00

HCHG SUTURE COMPLEX-SCALP+-1.1-2.5

Facility

$3,187.00

Service Code	HCPCS 13120
Hospital Charge Code	H4500728
Hospital Revenue Code	450
Min. Negotiated Rate	$2,708.95
Max. Negotiated Rate	$3,091.39
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39

HCHG SUTURE COMPLEX-SCALP+-2.6-7.5

Facility

$3,187.00

Service Code	HCPCS 13121
Hospital Charge Code	H4500730
Hospital Revenue Code	450
Min. Negotiated Rate	$2,708.95
Max. Negotiated Rate	$3,091.39
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39

HCHG SUTURE COMPLEX-SCALP+-2.6-7.5

Facility

$3,187.00

Service Code	HCPCS 13121
Hospital Charge Code	H4500730
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,593.50
Rate for Payer: AlohaCare Medicare	$2,868.30
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Devoted Health Medicare	$3,155.13
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,868.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.65
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Humana Medicare	$2,868.30
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39
Rate for Payer: Ohana Health Plan Medicaid	$2,868.30
Rate for Payer: Ohana Health Plan Medicare	$2,868.30
Rate for Payer: UnitedHealthcare Medicare	$2,868.30
Rate for Payer: University Health Alliance Commercial	$5,160.40

HCHG SUTURE COMPLEX-SCALP+-ADDL 5

Facility

$480.00

Service Code	HCPCS 13122
Hospital Charge Code	H4500732
Hospital Revenue Code	450
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$465.60
Rate for Payer: Cash Price	$312.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Kaiser Permanente Commercial	$432.00
Rate for Payer: MDX Hawaii PPO	$465.60

HCHG SUTURE COMPLEX-SCALP+-ADDL 5

Facility

$480.00

Service Code	HCPCS 13122
Hospital Charge Code	H4500732
Hospital Revenue Code	450
Min. Negotiated Rate	$240.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$240.00
Rate for Payer: AlohaCare Medicare	$432.00
Rate for Payer: Cash Price	$312.00
Rate for Payer: Cash Price	$312.00
Rate for Payer: Devoted Health Medicare	$475.20
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$432.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$456.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Humana Medicare	$432.00
Rate for Payer: Kaiser Permanente Commercial	$432.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$432.00
Rate for Payer: MDX Hawaii PPO	$465.60
Rate for Payer: Ohana Health Plan Medicaid	$432.00
Rate for Payer: Ohana Health Plan Medicare	$432.00
Rate for Payer: UnitedHealthcare Medicare	$432.00
Rate for Payer: University Health Alliance Commercial	$349.87

HCHG SUTURE COMPLEX-TRUNK-2.6-7.5

Facility

$3,199.00

Service Code	HCPCS 13101
Hospital Charge Code	H4500736
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$3,167.01
Rate for Payer: AlohaCare Medicaid	$1,599.50
Rate for Payer: AlohaCare Medicare	$2,879.10
Rate for Payer: Cash Price	$2,079.35
Rate for Payer: Cash Price	$2,079.35
Rate for Payer: Devoted Health Medicare	$3,167.01
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,879.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,039.05
Rate for Payer: Health Management Network Commercial	$2,719.15
Rate for Payer: Humana Medicare	$2,879.10
Rate for Payer: Kaiser Permanente Commercial	$2,879.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,879.10
Rate for Payer: MDX Hawaii PPO	$3,103.03
Rate for Payer: Ohana Health Plan Medicaid	$2,879.10
Rate for Payer: Ohana Health Plan Medicare	$2,879.10
Rate for Payer: UnitedHealthcare Medicare	$2,879.10
Rate for Payer: University Health Alliance Commercial	$2,331.75

HCHG SUTURE COMPLEX-TRUNK-2.6-7.5

Facility

$3,199.00

Service Code	HCPCS 13101
Hospital Charge Code	H4500736
Hospital Revenue Code	450
Min. Negotiated Rate	$2,719.15
Max. Negotiated Rate	$3,103.03
Rate for Payer: Cash Price	$2,079.35
Rate for Payer: Health Management Network Commercial	$2,719.15
Rate for Payer: Kaiser Permanente Commercial	$2,879.10
Rate for Payer: MDX Hawaii PPO	$3,103.03

HCHG SUTURE COMPLEX-TRUNK-ADDL 5

Facility

$728.00

Service Code	HCPCS 13102
Hospital Charge Code	H4500738
Hospital Revenue Code	450
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

HCHG SUTURE COMPLEX-TRUNK-ADDL 5

Facility

$728.00

Service Code	HCPCS 13102
Hospital Charge Code	H4500738
Hospital Revenue Code	450
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$364.00
Rate for Payer: AlohaCare Medicare	$655.20
Rate for Payer: Cash Price	$473.20
Rate for Payer: Cash Price	$473.20
Rate for Payer: Devoted Health Medicare	$720.72
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$655.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$691.60
Rate for Payer: Health Management Network Commercial	$618.80
Rate for Payer: Humana Medicare	$655.20
Rate for Payer: Kaiser Permanente Commercial	$655.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$655.20
Rate for Payer: MDX Hawaii PPO	$706.16
Rate for Payer: Ohana Health Plan Medicaid	$655.20
Rate for Payer: Ohana Health Plan Medicare	$655.20
Rate for Payer: UnitedHealthcare Medicare	$655.20
Rate for Payer: University Health Alliance Commercial	$530.64

HCHG SUTURE INTER-FACE+-2.5 OR LESS

Facility

$2,246.00

Service Code	HCPCS 12051
Hospital Charge Code	H4500742
Hospital Revenue Code	450
Min. Negotiated Rate	$1,909.10
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62

HCHG SUTURE INTER-FACE+-2.5 OR LESS

Facility

$2,246.00

Service Code	HCPCS 12051
Hospital Charge Code	H4500742
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,123.00
Rate for Payer: AlohaCare Medicare	$2,021.40
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Devoted Health Medicare	$2,223.54
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,021.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,133.70
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Humana Medicare	$2,021.40
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62
Rate for Payer: Ohana Health Plan Medicaid	$2,021.40
Rate for Payer: Ohana Health Plan Medicare	$2,021.40
Rate for Payer: UnitedHealthcare Medicare	$2,021.40
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG SUTURE INTER-FACE+-2.6-5.0

Facility

$2,246.00

Service Code	HCPCS 12052
Hospital Charge Code	H4500744
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$2,223.54
Rate for Payer: AlohaCare Medicaid	$1,123.00
Rate for Payer: AlohaCare Medicare	$2,021.40
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Devoted Health Medicare	$2,223.54
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,021.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,133.70
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Humana Medicare	$2,021.40
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62
Rate for Payer: Ohana Health Plan Medicaid	$2,021.40
Rate for Payer: Ohana Health Plan Medicare	$2,021.40
Rate for Payer: UnitedHealthcare Medicare	$2,021.40
Rate for Payer: University Health Alliance Commercial	$1,637.11

HCHG SUTURE INTER-FACE+-2.6-5.0

Facility

$2,246.00

Service Code	HCPCS 12052
Hospital Charge Code	H4500744
Hospital Revenue Code	450
Min. Negotiated Rate	$1,909.10
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62

HCHG SUTURE INTER-FACE+-5.1-7.5

Facility

$2,246.00

Service Code	HCPCS 12053
Hospital Charge Code	H4500748
Hospital Revenue Code	450
Min. Negotiated Rate	$1,909.10
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,459.90
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Kaiser Permanente Commercial	$2,021.40
Rate for Payer: MDX Hawaii PPO	$2,178.62

Know your out-of-pocket cost for care.

All Charges