Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG CLSD TX MONTEG FX DISLOC ELBOW W MANIP

Facility

$3,560.00

Service Code	HCPCS 24620
Hospital Charge Code	H4500254
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,780.00
Rate for Payer: AlohaCare Medicare	$3,204.00
Rate for Payer: Cash Price	$2,314.00
Rate for Payer: Cash Price	$2,314.00
Rate for Payer: Devoted Health Medicare	$3,524.40
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	$3,204.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,382.00
Rate for Payer: Health Management Network Commercial	$3,026.00
Rate for Payer: Humana Medicare	$3,204.00
Rate for Payer: Kaiser Permanente Commercial	$3,204.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,204.00
Rate for Payer: MDX Hawaii PPO	$3,453.20
Rate for Payer: Ohana Health Plan Medicaid	$3,204.00
Rate for Payer: Ohana Health Plan Medicare	$3,204.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,204.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG CLSD TX MTP JNT DISLOC WO ANESTH

Facility

$1,441.00

Service Code	HCPCS 28630
Hospital Charge Code	H4500256
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$720.50
Rate for Payer: AlohaCare Medicare	$1,296.90
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$1,426.59
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	$1,296.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,368.95
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Humana Medicare	$1,296.90
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$1,296.90
Rate for Payer: Ohana Health Plan Medicare	$1,296.90
Rate for Payer: UnitedHealthcare Medicare	$1,296.90
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX MTP JNT DISLOC WO ANESTH

Facility

$1,441.00

Service Code	HCPCS 28630
Hospital Charge Code	H4500256
Hospital Revenue Code	450
Min. Negotiated Rate	$1,224.85
Max. Negotiated Rate	$1,397.77
Rate for Payer: Cash Price	$936.65
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX NASAL BONE FX WO STABIL

Facility

$4,554.00

Service Code	HCPCS 21315
Hospital Charge Code	H4500260
Hospital Revenue Code	450
Min. Negotiated Rate	$3,870.90
Max. Negotiated Rate	$4,417.38
Rate for Payer: Cash Price	$2,960.10
Rate for Payer: Health Management Network Commercial	$3,870.90
Rate for Payer: Kaiser Permanente Commercial	$4,098.60
Rate for Payer: MDX Hawaii PPO	$4,417.38

HCHG CLSD TX NASAL BONE FX WO STABIL

Facility

$4,554.00

Service Code	HCPCS 21315
Hospital Charge Code	H4500260
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,508.46
Rate for Payer: AlohaCare Medicaid	$2,277.00
Rate for Payer: AlohaCare Medicare	$4,098.60
Rate for Payer: Cash Price	$2,960.10
Rate for Payer: Cash Price	$2,960.10
Rate for Payer: Devoted Health Medicare	$4,508.46
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	$4,098.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,326.30
Rate for Payer: Health Management Network Commercial	$3,870.90
Rate for Payer: Humana Medicare	$4,098.60
Rate for Payer: Kaiser Permanente Commercial	$4,098.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,098.60
Rate for Payer: MDX Hawaii PPO	$4,417.38
Rate for Payer: Ohana Health Plan Medicaid	$4,098.60
Rate for Payer: Ohana Health Plan Medicare	$4,098.60
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,098.60
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG CLSD TX NOSE/JAW FX

Facility

$6,598.00

Service Code	HCPCS 21345
Hospital Charge Code	K4500009
Hospital Revenue Code	450
Min. Negotiated Rate	$5,608.30
Max. Negotiated Rate	$6,400.06
Rate for Payer: Cash Price	$4,288.70
Rate for Payer: Health Management Network Commercial	$5,608.30
Rate for Payer: Kaiser Permanente Commercial	$5,938.20
Rate for Payer: MDX Hawaii PPO	$6,400.06

HCHG CLSD TX NOSE/JAW FX

Facility

$6,598.00

Service Code	HCPCS 21345
Hospital Charge Code	K4500009
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$16,700.00
Rate for Payer: AlohaCare Medicaid	$3,299.00
Rate for Payer: AlohaCare Medicare	$5,938.20
Rate for Payer: Cash Price	$4,288.70
Rate for Payer: Cash Price	$4,288.70
Rate for Payer: Devoted Health Medicare	$6,532.02
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	$5,938.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,268.10
Rate for Payer: Health Management Network Commercial	$5,608.30
Rate for Payer: Humana Medicare	$5,938.20
Rate for Payer: Kaiser Permanente Commercial	$5,938.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$5,938.20
Rate for Payer: MDX Hawaii PPO	$6,400.06
Rate for Payer: Ohana Health Plan Medicaid	$5,938.20
Rate for Payer: Ohana Health Plan Medicare	$5,938.20
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$5,938.20
Rate for Payer: University Health Alliance Commercial	$16,700.00

HCHG CLSD TX PATELLAR DISLOC

Facility

$1,441.00

Service Code	HCPCS 27560
Hospital Charge Code	H4500398
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$720.50
Rate for Payer: AlohaCare Medicare	$1,296.90
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$1,426.59
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	$1,296.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,368.95
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Humana Medicare	$1,296.90
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$1,296.90
Rate for Payer: Ohana Health Plan Medicare	$1,296.90
Rate for Payer: UnitedHealthcare Medicare	$1,296.90
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX PATELLAR DISLOC

Facility

$1,441.00

Service Code	HCPCS 27560
Hospital Charge Code	H4500398
Hospital Revenue Code	450
Min. Negotiated Rate	$1,224.85
Max. Negotiated Rate	$1,397.77
Rate for Payer: Cash Price	$936.65
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX PHALANGEAL SHFT FX W MANIP EA

Facility

$1,441.00

Service Code	HCPCS 26725
Hospital Charge Code	H4500268
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$720.50
Rate for Payer: AlohaCare Medicare	$1,296.90
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$1,426.59
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	$1,296.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,368.95
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Humana Medicare	$1,296.90
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$1,296.90
Rate for Payer: Ohana Health Plan Medicare	$1,296.90
Rate for Payer: UnitedHealthcare Medicare	$1,296.90
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX PHALANGEAL SHFT FX W MANIP EA

Facility

$1,441.00

Service Code	HCPCS 26725
Hospital Charge Code	H4500268
Hospital Revenue Code	450
Min. Negotiated Rate	$1,224.85
Max. Negotiated Rate	$1,397.77
Rate for Payer: Cash Price	$936.65
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX POST HIP ARTH WO ANESTH

Facility

$1,441.00

Service Code	HCPCS 27265
Hospital Charge Code	H4500270
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$720.50
Rate for Payer: AlohaCare Medicare	$1,296.90
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$1,426.59
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	$1,296.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,368.95
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Humana Medicare	$1,296.90
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$1,296.90
Rate for Payer: Ohana Health Plan Medicare	$1,296.90
Rate for Payer: UnitedHealthcare Medicare	$1,296.90
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX POST HIP ARTH WO ANESTH

Facility

$1,441.00

Service Code	HCPCS 27265
Hospital Charge Code	H4500270
Hospital Revenue Code	450
Min. Negotiated Rate	$1,224.85
Max. Negotiated Rate	$1,397.77
Rate for Payer: Cash Price	$936.65
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX PROX FIB/SHFT FX W MANIP

Facility

$5,779.00

Service Code	HCPCS 27781
Hospital Charge Code	H4500274
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,721.21
Rate for Payer: AlohaCare Medicaid	$2,889.50
Rate for Payer: AlohaCare Medicare	$5,201.10
Rate for Payer: Cash Price	$3,756.35
Rate for Payer: Cash Price	$3,756.35
Rate for Payer: Devoted Health Medicare	$5,721.21
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	$5,201.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,490.05
Rate for Payer: Health Management Network Commercial	$4,912.15
Rate for Payer: Humana Medicare	$5,201.10
Rate for Payer: Kaiser Permanente Commercial	$5,201.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$5,201.10
Rate for Payer: MDX Hawaii PPO	$5,605.63
Rate for Payer: Ohana Health Plan Medicaid	$5,201.10
Rate for Payer: Ohana Health Plan Medicare	$5,201.10
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$5,201.10
Rate for Payer: University Health Alliance Commercial	$4,212.31

HCHG CLSD TX PROX FIB/SHFT FX W MANIP

Facility

$5,779.00

Service Code	HCPCS 27781
Hospital Charge Code	H4500274
Hospital Revenue Code	450
Min. Negotiated Rate	$4,912.15
Max. Negotiated Rate	$5,605.63
Rate for Payer: Cash Price	$3,756.35
Rate for Payer: Health Management Network Commercial	$4,912.15
Rate for Payer: Kaiser Permanente Commercial	$5,201.10
Rate for Payer: MDX Hawaii PPO	$5,605.63

HCHG CLSD TX RADL HEAD/NECK FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 24655
Hospital Charge Code	H4500290
Hospital Revenue Code	450
Min. Negotiated Rate	$3,999.25
Max. Negotiated Rate	$4,563.85
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: Kaiser Permanente Commercial	$4,234.50
Rate for Payer: MDX Hawaii PPO	$4,563.85

HCHG CLSD TX RADL HEAD/NECK FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 24655
Hospital Charge Code	H4500290
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,657.95
Rate for Payer: AlohaCare Medicaid	$2,352.50
Rate for Payer: AlohaCare Medicare	$4,234.50
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$4,657.95
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	$4,234.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.75
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: Humana Medicare	$4,234.50
Rate for Payer: Kaiser Permanente Commercial	$4,234.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,234.50
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$4,234.50
Rate for Payer: Ohana Health Plan Medicare	$4,234.50
Rate for Payer: UnitedHealthcare Medicare	$4,234.50
Rate for Payer: University Health Alliance Commercial	$3,429.47

HCHG CLSD TX RAD SHAFT FX W DISLOC

Facility

$3,350.00

Service Code	HCPCS 25520
Hospital Charge Code	H4500282
Hospital Revenue Code	450
Min. Negotiated Rate	$2,847.50
Max. Negotiated Rate	$3,249.50
Rate for Payer: Cash Price	$2,177.50
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: Kaiser Permanente Commercial	$3,015.00
Rate for Payer: MDX Hawaii PPO	$3,249.50

HCHG CLSD TX RAD SHAFT FX W DISLOC

Facility

$3,350.00

Service Code	HCPCS 25520
Hospital Charge Code	H4500282
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$3,316.50
Rate for Payer: AlohaCare Medicaid	$1,675.00
Rate for Payer: AlohaCare Medicare	$3,015.00
Rate for Payer: Cash Price	$2,177.50
Rate for Payer: Cash Price	$2,177.50
Rate for Payer: Devoted Health Medicare	$3,316.50
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	$3,015.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,182.50
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: Humana Medicare	$3,015.00
Rate for Payer: Kaiser Permanente Commercial	$3,015.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,015.00
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: Ohana Health Plan Medicaid	$3,015.00
Rate for Payer: Ohana Health Plan Medicare	$3,015.00
Rate for Payer: UnitedHealthcare Medicare	$3,015.00
Rate for Payer: University Health Alliance Commercial	$2,441.82

HCHG CLSD TX RAD SHAFT FX W MANIP

Facility

$6,964.00

Service Code	HCPCS 25505
Hospital Charge Code	H4500284
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,894.36
Rate for Payer: AlohaCare Medicaid	$3,482.00
Rate for Payer: AlohaCare Medicare	$6,267.60
Rate for Payer: Cash Price	$4,526.60
Rate for Payer: Cash Price	$4,526.60
Rate for Payer: Devoted Health Medicare	$6,894.36
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	$6,267.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,615.80
Rate for Payer: Health Management Network Commercial	$5,919.40
Rate for Payer: Humana Medicare	$6,267.60
Rate for Payer: Kaiser Permanente Commercial	$6,267.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$6,267.60
Rate for Payer: MDX Hawaii PPO	$6,755.08
Rate for Payer: Ohana Health Plan Medicaid	$6,267.60
Rate for Payer: Ohana Health Plan Medicare	$6,267.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$6,267.60
Rate for Payer: University Health Alliance Commercial	$5,076.06

HCHG CLSD TX RAD SHAFT FX W MANIP

Facility

$6,964.00

Service Code	HCPCS 25505
Hospital Charge Code	H4500284
Hospital Revenue Code	450
Min. Negotiated Rate	$5,919.40
Max. Negotiated Rate	$6,755.08
Rate for Payer: Cash Price	$4,526.60
Rate for Payer: Health Management Network Commercial	$5,919.40
Rate for Payer: Kaiser Permanente Commercial	$6,267.60
Rate for Payer: MDX Hawaii PPO	$6,755.08

HCHG CLSD TX RAD/ULNA SHAFT FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 25565
Hospital Charge Code	H4500286
Hospital Revenue Code	450
Min. Negotiated Rate	$3,999.25
Max. Negotiated Rate	$4,563.85
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: Kaiser Permanente Commercial	$4,234.50
Rate for Payer: MDX Hawaii PPO	$4,563.85

HCHG CLSD TX RAD/ULNA SHAFT FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 25565
Hospital Charge Code	H4500286
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$2,352.50
Rate for Payer: AlohaCare Medicare	$4,234.50
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$4,657.95
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	$4,234.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.75
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: Humana Medicare	$4,234.50
Rate for Payer: Kaiser Permanente Commercial	$4,234.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,234.50
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$4,234.50
Rate for Payer: Ohana Health Plan Medicare	$4,234.50
Rate for Payer: UnitedHealthcare Medicare	$4,234.50
Rate for Payer: University Health Alliance Commercial	$10,679.55

HCHG CLSD TX SCAPULAR FX WO MANIP

Facility

$1,441.00

Service Code	HCPCS 23570
Hospital Charge Code	H4500296
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$720.50
Rate for Payer: AlohaCare Medicare	$1,296.90
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$1,426.59
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	$1,296.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,368.95
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Humana Medicare	$1,296.90
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$1,296.90
Rate for Payer: Ohana Health Plan Medicare	$1,296.90
Rate for Payer: UnitedHealthcare Medicare	$1,296.90
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX SCAPULAR FX WO MANIP

Facility

$1,441.00

Service Code	HCPCS 23570
Hospital Charge Code	H4500296
Hospital Revenue Code	450
Min. Negotiated Rate	$1,224.85
Max. Negotiated Rate	$1,397.77
Rate for Payer: Cash Price	$936.65
Rate for Payer: Health Management Network Commercial	$1,224.85
Rate for Payer: Kaiser Permanente Commercial	$1,296.90
Rate for Payer: MDX Hawaii PPO	$1,397.77

Know your out-of-pocket cost for care.

All Charges