Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG SUTURE SIMP-FACE+-2.5 OR LESS

Facility

$1,233.00

Service Code	HCPCS 12011
Hospital Charge Code	H4500780
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-FACE+-2.5 OR LESS

Facility

$1,233.00

Service Code	HCPCS 12011
Hospital Charge Code	H4500780
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-FACE+-2.6-5.0

Facility

$1,233.00

Service Code	HCPCS 12013
Hospital Charge Code	H4500782
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-FACE+-2.6-5.0

Facility

$1,233.00

Service Code	HCPCS 12013
Hospital Charge Code	H4500782
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-FACE+-5.1-7.5

Facility

$1,233.00

Service Code	HCPCS 12014
Hospital Charge Code	H4500786
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-FACE+-5.1-7.5

Facility

$1,233.00

Service Code	HCPCS 12014
Hospital Charge Code	H4500786
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-FACE+-7.6-12.5

Facility

$1,233.00

Service Code	HCPCS 12015
Hospital Charge Code	H4500788
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-FACE+-7.6-12.5

Facility

$1,233.00

Service Code	HCPCS 12015
Hospital Charge Code	H4500788
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-SCALP+-12.6-20.0

Facility

$2,246.00

Service Code	HCPCS 12005
Hospital Charge Code	H4500792
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 SIMP-SCALP+-12.6-20.0

Facility

$2,246.00

Service Code	HCPCS 12005
Hospital Charge Code	H4500792
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 SIMP-SCALP+-20.1-30.0

Facility

$2,246.00

Service Code	HCPCS 12006
Hospital Charge Code	H4500798
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 SIMP-SCALP+-20.1-30.0

Facility

$2,246.00

Service Code	HCPCS 12006
Hospital Charge Code	H4500798
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 SIMP-SCALP+-2.5 OR LESS

Facility

$1,233.00

Service Code	HCPCS 12001
Hospital Charge Code	H4500794
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-SCALP+-2.5 OR LESS

Facility

$1,233.00

Service Code	HCPCS 12001
Hospital Charge Code	H4500794
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-SCALP+-2.6-7.5

Facility

$1,233.00

Service Code	HCPCS 12002
Hospital Charge Code	H4500796
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-SCALP+-2.6-7.5

Facility

$1,233.00

Service Code	HCPCS 12002
Hospital Charge Code	H4500796
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-SCALP+-7.6-12.5

Facility

$1,233.00

Service Code	HCPCS 12004
Hospital Charge Code	H4500800
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SUTURE SIMP-SCALP+-7.6-12.5

Facility

$1,233.00

Service Code	HCPCS 12004
Hospital Charge Code	H4500800
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-SCALP+-OVER 30.0

Facility

$1,233.00

Service Code	HCPCS 12007
Hospital Charge Code	H4500802
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG SUTURE SIMP-SCALP+-OVER 30.0

Facility

$1,233.00

Service Code	HCPCS 12007
Hospital Charge Code	H4500802
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$616.50
Rate for Payer: AlohaCare Medicare	$1,109.70
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$1,220.67
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	$1,109.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$1,109.70
Rate for Payer: Kaiser Permanente Commercial	$1,109.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,109.70
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$1,109.70
Rate for Payer: Ohana Health Plan Medicare	$1,109.70
Rate for Payer: UnitedHealthcare Medicare	$1,109.70
Rate for Payer: University Health Alliance Commercial	$898.73

HCHG SVN SUB TX

Facility

$1,256.00

Service Code	HCPCS 94640
Hospital Charge Code	H4100273
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$1,243.44
Rate for Payer: AlohaCare Medicaid	$628.00
Rate for Payer: AlohaCare Medicare	$1,130.40
Rate for Payer: Cash Price	$816.40
Rate for Payer: Cash Price	$816.40
Rate for Payer: Devoted Health Medicare	$1,243.44
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1,130.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,193.20
Rate for Payer: Health Management Network Commercial	$1,067.60
Rate for Payer: Humana Medicare	$1,130.40
Rate for Payer: Kaiser Permanente Commercial	$1,130.40
Rate for Payer: Kaiser Permanente Medicaid	$640.56
Rate for Payer: Kaiser Permanente Medicare	$1,130.40
Rate for Payer: MDX Hawaii PPO	$1,218.32
Rate for Payer: Ohana Health Plan Medicaid	$1,130.40
Rate for Payer: Ohana Health Plan Medicare	$1,130.40
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$1,130.40
Rate for Payer: University Health Alliance Commercial	$915.50

HCHG SVN SUB TX

Facility

$1,256.00

Service Code	HCPCS 94640
Hospital Charge Code	H4100273
Hospital Revenue Code	410
Min. Negotiated Rate	$1,067.60
Max. Negotiated Rate	$1,218.32
Rate for Payer: Cash Price	$816.40
Rate for Payer: Health Management Network Commercial	$1,067.60
Rate for Payer: Kaiser Permanente Commercial	$1,130.40
Rate for Payer: MDX Hawaii PPO	$1,218.32

HCHG SVN TX, DAILY

Facility

$1,256.00

Service Code	HCPCS 94640
Hospital Charge Code	H4100272
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$1,243.44
Rate for Payer: AlohaCare Medicaid	$628.00
Rate for Payer: AlohaCare Medicare	$1,130.40
Rate for Payer: Cash Price	$816.40
Rate for Payer: Cash Price	$816.40
Rate for Payer: Devoted Health Medicare	$1,243.44
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1,130.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,193.20
Rate for Payer: Health Management Network Commercial	$1,067.60
Rate for Payer: Humana Medicare	$1,130.40
Rate for Payer: Kaiser Permanente Commercial	$1,130.40
Rate for Payer: Kaiser Permanente Medicaid	$640.56
Rate for Payer: Kaiser Permanente Medicare	$1,130.40
Rate for Payer: MDX Hawaii PPO	$1,218.32
Rate for Payer: Ohana Health Plan Medicaid	$1,130.40
Rate for Payer: Ohana Health Plan Medicare	$1,130.40
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$1,130.40
Rate for Payer: University Health Alliance Commercial	$915.50

HCHG SVN TX, DAILY

Facility

$1,256.00

Service Code	HCPCS 94640
Hospital Charge Code	H4100272
Hospital Revenue Code	410
Min. Negotiated Rate	$1,067.60
Max. Negotiated Rate	$1,218.32
Rate for Payer: Cash Price	$816.40
Rate for Payer: Health Management Network Commercial	$1,067.60
Rate for Payer: Kaiser Permanente Commercial	$1,130.40
Rate for Payer: MDX Hawaii PPO	$1,218.32

HCHG SVN W PEAK FLOW, DAILY

Facility

$1,256.00

Service Code	HCPCS 94640
Hospital Charge Code	H4100276
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$1,243.44
Rate for Payer: AlohaCare Medicaid	$628.00
Rate for Payer: AlohaCare Medicare	$1,130.40
Rate for Payer: Cash Price	$816.40
Rate for Payer: Cash Price	$816.40
Rate for Payer: Devoted Health Medicare	$1,243.44
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$1,130.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,193.20
Rate for Payer: Health Management Network Commercial	$1,067.60
Rate for Payer: Humana Medicare	$1,130.40
Rate for Payer: Kaiser Permanente Commercial	$1,130.40
Rate for Payer: Kaiser Permanente Medicaid	$640.56
Rate for Payer: Kaiser Permanente Medicare	$1,130.40
Rate for Payer: MDX Hawaii PPO	$1,218.32
Rate for Payer: Ohana Health Plan Medicaid	$1,130.40
Rate for Payer: Ohana Health Plan Medicare	$1,130.40
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$1,130.40
Rate for Payer: University Health Alliance Commercial	$915.50

Know your out-of-pocket cost for care.

All Charges