Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG CLSD TX DISTAL PHALAN FX W MANIP EA

Facility

$1,441.00

Service Code	HCPCS 26755
Hospital Charge Code	H4500202
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX DISTAL PHALAN FX W MANIP EA

Facility

$1,441.00

Service Code	HCPCS 26755
Hospital Charge Code	H4500202
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX DISTAL RADIAL FX

Facility

$1,441.00

Service Code	HCPCS 25600
Hospital Charge Code	H4500206
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$20,300.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$20,300.00

HCHG CLSD TX DISTAL RADIAL FX

Facility

$1,441.00

Service Code	HCPCS 25600
Hospital Charge Code	H4500206
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX DIST BIFULAR FX

Facility

$1,441.00

Service Code	HCPCS 27786
Hospital Charge Code	H4500194
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX DIST BIFULAR FX

Facility

$1,441.00

Service Code	HCPCS 27786
Hospital Charge Code	H4500194
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX DIST FIB FX(LAT) W MANIP

Facility

$1,441.00

Service Code	HCPCS 27788
Hospital Charge Code	H4500196
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX DIST FIB FX(LAT) W MANIP

Facility

$1,441.00

Service Code	HCPCS 27788
Hospital Charge Code	H4500196
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX DIST RADIAL FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 25605
Hospital Charge Code	H4500198
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: MDX Hawaii PPO	$4,563.85

HCHG CLSD TX DIST RADIAL FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 25605
Hospital Charge Code	H4500198
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
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	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$2,964.15
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$5,160.40

HCHG CLSD TX FEM FX DISTAL END W MANIP

Facility

$4,705.00

Service Code	HCPCS 27510
Hospital Charge Code	H4500208
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$4,563.85
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$2,964.15
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$3,429.47

HCHG CLSD TX FEM FX DISTAL END W MANIP

Facility

$4,705.00

Service Code	HCPCS 27510
Hospital Charge Code	H4500208
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: MDX Hawaii PPO	$4,563.85

HCHG CLSD TX FEM SHFT FX W MANIP TRAC

Facility

$4,109.00

Service Code	HCPCS 27502
Hospital Charge Code	H4500216
Hospital Revenue Code	450
Min. Negotiated Rate	$3,492.65
Max. Negotiated Rate	$3,985.73
Rate for Payer: Cash Price	$2,670.85
Rate for Payer: Health Management Network Commercial	$3,492.65
Rate for Payer: MDX Hawaii PPO	$3,985.73

HCHG CLSD TX FEM SHFT FX W MANIP TRAC

Facility

$4,109.00

Service Code	HCPCS 27502
Hospital Charge Code	H4500216
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$2,670.85
Rate for Payer: Cash Price	$2,670.85
Rate for Payer: Cash Price	$2,670.85
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,903.55
Rate for Payer: Health Management Network Commercial	$3,492.65
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$2,588.67
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$3,985.73
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$2,995.05

HCHG CLSD TX FINGER DISLOC (IP)

Facility

$1,441.00

Service Code	HCPCS 26770
Hospital Charge Code	H4500396
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX FINGER DISLOC (IP)

Facility

$1,441.00

Service Code	HCPCS 26770
Hospital Charge Code	H4500396
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX FX GREAT TOE W MANIP

Facility

$1,441.00

Service Code	HCPCS 28495
Hospital Charge Code	H4500222
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX FX GREAT TOE W MANIP

Facility

$1,441.00

Service Code	HCPCS 28495
Hospital Charge Code	H4500222
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX FX NOT GR TOE W MANIP EA

Facility

$1,441.00

Service Code	HCPCS 28515
Hospital Charge Code	H4500454
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX FX NOT GR TOE W MANIP EA

Facility

$1,441.00

Service Code	HCPCS 28515
Hospital Charge Code	H4500454
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX HIP DISLOC WO ANESTH

Facility

$1,441.00

Service Code	HCPCS 27250
Hospital Charge Code	H4500228
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: MDX Hawaii PPO	$1,397.77

HCHG CLSD TX HIP DISLOC WO ANESTH

Facility

$1,441.00

Service Code	HCPCS 27250
Hospital Charge Code	H4500228
Hospital Revenue Code	450
Min. Negotiated Rate	$291.40
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$291.40
Rate for Payer: AlohaCare Medicare	$291.40
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Cash Price	$936.65
Rate for Payer: Devoted Health Medicare	$320.54
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$291.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
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	$291.40
Rate for Payer: Kaiser Permanente Commercial	$907.83
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$291.40
Rate for Payer: MDX Hawaii PPO	$1,397.77
Rate for Payer: Ohana Health Plan Medicaid	$320.54
Rate for Payer: Ohana Health Plan Medicare	$291.40
Rate for Payer: UnitedHealthcare Medicare	$291.40
Rate for Payer: University Health Alliance Commercial	$1,050.34

HCHG CLSD TX HUM EPICON FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 24565
Hospital Charge Code	H4500230
Hospital Revenue Code	450
Min. Negotiated Rate	$848.00
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
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	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$2,964.15
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$3,429.47

HCHG CLSD TX HUM EPICON FX W MANIP

Facility

$4,705.00

Service Code	HCPCS 24565
Hospital Charge Code	H4500230
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: MDX Hawaii PPO	$4,563.85

HCHG CLSD TX HUMERAL EPICONDYLAR FX MEDIAL/LATERAL WO MANIP

Facility

$1,365.00

Service Code	HCPCS 24560
Hospital Charge Code	H4500893
Hospital Revenue Code	450
Min. Negotiated Rate	$1,160.25
Max. Negotiated Rate	$1,324.05
Rate for Payer: Cash Price	$887.25
Rate for Payer: Health Management Network Commercial	$1,160.25
Rate for Payer: MDX Hawaii PPO	$1,324.05

Know your out-of-pocket cost for care.

All Charges