Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG INJ ANES AGENT SPHENOPALATINE GANGLION

Facility

$1,721.00

Service Code	HCPCS 64505
Hospital Charge Code	H4501123
Hospital Revenue Code	450
Min. Negotiated Rate	$362.62
Max. Negotiated Rate	$2,833.00
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$398.88
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	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$1,084.23
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$1,254.44

HCHG INJ ANES AGENT SPHENOPALATINE GANGLION

Facility

$1,721.00

Service Code	HCPCS 64505
Hospital Charge Code	H4501123
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ ANES AXILLARY NERVE

Facility

$3,472.00

Service Code	HCPCS 64417
Hospital Charge Code	H3610481
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,367.84
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$2,256.80
Rate for Payer: Cash Price	$2,256.80
Rate for Payer: Cash Price	$2,256.80
Rate for Payer: Devoted Health Medicare	$1,149.36
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	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$2,951.20
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,187.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$3,367.84
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$2,530.74

HCHG INJ ANES AXILLARY NERVE

Facility

$3,472.00

Service Code	HCPCS 64417
Hospital Charge Code	H3610481
Hospital Revenue Code	361
Min. Negotiated Rate	$2,951.20
Max. Negotiated Rate	$3,367.84
Rate for Payer: Cash Price	$2,256.80
Rate for Payer: Health Management Network Commercial	$2,951.20
Rate for Payer: MDX Hawaii PPO	$3,367.84

HCHG INJ ANES BRACHIAL PLEX SINGLE

Facility

$5,061.00

Service Code	HCPCS 64415
Hospital Charge Code	H3610483
Hospital Revenue Code	361
Min. Negotiated Rate	$4,301.85
Max. Negotiated Rate	$4,909.17
Rate for Payer: Cash Price	$3,289.65
Rate for Payer: Health Management Network Commercial	$4,301.85
Rate for Payer: MDX Hawaii PPO	$4,909.17

HCHG INJ ANES BRACHIAL PLEX SINGLE

Facility

$5,061.00

Service Code	HCPCS 64415
Hospital Charge Code	H3610483
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,909.17
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$3,289.65
Rate for Payer: Cash Price	$3,289.65
Rate for Payer: Cash Price	$3,289.65
Rate for Payer: Devoted Health Medicare	$1,149.36
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	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$4,301.85
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$3,188.43
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$4,909.17
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$3,688.96

HCHG INJ ANES BRACHIAL PLEX W/CATH

Facility

$4,633.00

Service Code	HCPCS 64416
Hospital Charge Code	H3610482
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,494.01
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$3,011.45
Rate for Payer: Cash Price	$3,011.45
Rate for Payer: Cash Price	$3,011.45
Rate for Payer: Devoted Health Medicare	$1,149.36
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	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$3,938.05
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$2,918.79
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$4,494.01
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$3,376.99

HCHG INJ ANES BRACHIAL PLEX W/CATH

Facility

$4,633.00

Service Code	HCPCS 64416
Hospital Charge Code	H3610482
Hospital Revenue Code	361
Min. Negotiated Rate	$3,938.05
Max. Negotiated Rate	$4,494.01
Rate for Payer: Cash Price	$3,011.45
Rate for Payer: Health Management Network Commercial	$3,938.05
Rate for Payer: MDX Hawaii PPO	$4,494.01

HCHG INJ ANES RETROBULBAR

Facility

$1,295.00

Service Code	HCPCS 67500
Hospital Charge Code	K3610002
Hospital Revenue Code	361
Min. Negotiated Rate	$37.86
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$374.96
Rate for Payer: AlohaCare Medicare	$374.96
Rate for Payer: Cash Price	$841.75
Rate for Payer: Cash Price	$841.75
Rate for Payer: Cash Price	$841.75
Rate for Payer: Devoted Health Medicare	$412.46
Rate for Payer: Hawaii Medical Service Association Commercial	$468.70
Rate for Payer: Hawaii Medical Service Association Medicare	$374.96
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: Humana Medicare	$374.96
Rate for Payer: Kaiser Permanente Commercial	$815.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$374.96
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: Ohana Health Plan Medicaid	$412.46
Rate for Payer: Ohana Health Plan Medicare	$374.96
Rate for Payer: UnitedHealthcare Medicaid	$37.86
Rate for Payer: UnitedHealthcare Medicare	$374.96
Rate for Payer: University Health Alliance Commercial	$943.93

HCHG INJ ANES RETROBULBAR

Facility

$1,295.00

Service Code	HCPCS 67500
Hospital Charge Code	K3610002
Hospital Revenue Code	361
Min. Negotiated Rate	$1,100.75
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$841.75
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: MDX Hawaii PPO	$1,256.15

HCHG INJ, ANESTH AGENT;FEMORAL NERVE,SINGLE

Facility

$3,351.00

Service Code	HCPCS 64447
Hospital Charge Code	H4501048
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$2,178.15
Rate for Payer: Cash Price	$2,178.15
Rate for Payer: Cash Price	$2,178.15
Rate for Payer: Devoted Health Medicare	$917.28
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	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,183.45
Rate for Payer: Health Management Network Commercial	$2,848.35
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$2,111.13
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$3,250.47
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ, ANESTH AGENT;FEMORAL NERVE,SINGLE

Facility

$3,351.00

Service Code	HCPCS 64447
Hospital Charge Code	H4501048
Hospital Revenue Code	450
Min. Negotiated Rate	$2,848.35
Max. Negotiated Rate	$3,250.47
Rate for Payer: Cash Price	$2,178.15
Rate for Payer: Health Management Network Commercial	$2,848.35
Rate for Payer: MDX Hawaii PPO	$3,250.47

HCHG INJ ANESTH AGT TRIG NERVE

Facility

$1,721.00

Service Code	HCPCS 64400
Hospital Charge Code	H4500504
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ ANESTH AGT TRIG NERVE

Facility

$1,721.00

Service Code	HCPCS 64400
Hospital Charge Code	H4500504
Hospital Revenue Code	450
Min. Negotiated Rate	$362.62
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$398.88
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	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$1,084.23
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ. ANESTHETIC AGENT; GREATER OCCIPITAL NERVE

Facility

$1,721.00

Service Code	HCPCS 64405
Hospital Charge Code	H4501113
Hospital Revenue Code	450
Min. Negotiated Rate	$362.62
Max. Negotiated Rate	$1,669.37
Rate for Payer: AlohaCare Medicaid	$362.62
Rate for Payer: AlohaCare Medicare	$362.62
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$398.88
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	$362.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$362.62
Rate for Payer: Kaiser Permanente Commercial	$1,084.23
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$362.62
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$398.88
Rate for Payer: Ohana Health Plan Medicare	$362.62
Rate for Payer: UnitedHealthcare Medicare	$362.62
Rate for Payer: University Health Alliance Commercial	$1,254.44

HCHG INJ. ANESTHETIC AGENT; GREATER OCCIPITAL NERVE

Facility

$1,721.00

Service Code	HCPCS 64405
Hospital Charge Code	H4501113
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ ANESTH; OTHR PERIPHERAL NRV/BRANCH

Facility

$4,132.00

Service Code	HCPCS 64450
Hospital Charge Code	K3610003
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$2,685.80
Rate for Payer: Cash Price	$2,685.80
Rate for Payer: Cash Price	$2,685.80
Rate for Payer: Devoted Health Medicare	$917.28
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	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$3,512.20
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$2,603.16
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$4,008.04
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ ANESTH; OTHR PERIPHERAL NRV/BRANCH

Facility

$3,593.00

Service Code	HCPCS 64450
Hospital Charge Code	H3601046
Hospital Revenue Code	510
Min. Negotiated Rate	$3,054.05
Max. Negotiated Rate	$3,485.21
Rate for Payer: Cash Price	$2,335.45
Rate for Payer: Health Management Network Commercial	$3,054.05
Rate for Payer: MDX Hawaii PPO	$3,485.21

HCHG INJ ANESTH; OTHR PERIPHERAL NRV/BRANCH

Facility

$4,132.00

Service Code	HCPCS 64450
Hospital Charge Code	K3610003
Hospital Revenue Code	361
Min. Negotiated Rate	$3,512.20
Max. Negotiated Rate	$4,008.04
Rate for Payer: Cash Price	$2,685.80
Rate for Payer: Health Management Network Commercial	$3,512.20
Rate for Payer: MDX Hawaii PPO	$4,008.04

HCHG INJ ANESTH; OTHR PERIPHERAL NRV/BRANCH

Facility

$3,593.00

Service Code	HCPCS 64450
Hospital Charge Code	H3601046
Hospital Revenue Code	510
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$2,335.45
Rate for Payer: Cash Price	$2,335.45
Rate for Payer: Cash Price	$2,335.45
Rate for Payer: Devoted Health Medicare	$917.28
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	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,413.35
Rate for Payer: Health Management Network Commercial	$3,054.05
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$2,263.59
Rate for Payer: Kaiser Permanente Medicaid	$1,832.43
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$3,485.21
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ ANES UNLISTED PROC, ORBIT

Facility

$1,295.00

Service Code	HCPCS 67599
Hospital Charge Code	K3610001
Hospital Revenue Code	361
Min. Negotiated Rate	$1,100.75
Max. Negotiated Rate	$1,256.15
Rate for Payer: Cash Price	$841.75
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: MDX Hawaii PPO	$1,256.15

HCHG INJ ANES UNLISTED PROC, ORBIT

Facility

$1,295.00

Service Code	HCPCS 67599
Hospital Charge Code	K3610001
Hospital Revenue Code	361
Min. Negotiated Rate	$224.20
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$374.96
Rate for Payer: AlohaCare Medicare	$374.96
Rate for Payer: Cash Price	$841.75
Rate for Payer: Cash Price	$841.75
Rate for Payer: Cash Price	$841.75
Rate for Payer: Devoted Health Medicare	$412.46
Rate for Payer: Hawaii Medical Service Association Commercial	$468.70
Rate for Payer: Hawaii Medical Service Association Medicare	$374.96
Rate for Payer: Health Management Network Commercial	$1,100.75
Rate for Payer: Humana Medicare	$374.96
Rate for Payer: Kaiser Permanente Commercial	$815.85
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$374.96
Rate for Payer: MDX Hawaii PPO	$1,256.15
Rate for Payer: Ohana Health Plan Medicaid	$412.46
Rate for Payer: Ohana Health Plan Medicare	$374.96
Rate for Payer: UnitedHealthcare Medicaid	$224.20
Rate for Payer: UnitedHealthcare Medicare	$374.96
Rate for Payer: University Health Alliance Commercial	$943.93

HCHG INJ DIAG/THER SUB LUMB/SAC W/ IMG GDE

Facility

$2,617.00

Service Code	HCPCS 62323
Hospital Charge Code	H3610659
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$833.89
Rate for Payer: AlohaCare Medicare	$833.89
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Devoted Health Medicare	$917.28
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	$833.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$2,224.45
Rate for Payer: Humana Medicare	$833.89
Rate for Payer: Kaiser Permanente Commercial	$1,648.71
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$833.89
Rate for Payer: MDX Hawaii PPO	$2,538.49
Rate for Payer: Ohana Health Plan Medicaid	$917.28
Rate for Payer: Ohana Health Plan Medicare	$833.89
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$833.89
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ DIAG/THER SUB LUMB/SAC W/ IMG GDE

Facility

$2,617.00

Service Code	HCPCS 62323
Hospital Charge Code	H3610659
Hospital Revenue Code	361
Min. Negotiated Rate	$2,224.45
Max. Negotiated Rate	$2,538.49
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Health Management Network Commercial	$2,224.45
Rate for Payer: MDX Hawaii PPO	$2,538.49

HCHG INJ DIAG/THER SUB LUMB/SAC W/O IMG GDE

Facility

$2,617.00

Service Code	HCPCS 62322
Hospital Charge Code	H3610661
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,044.87
Rate for Payer: AlohaCare Medicare	$1,044.87
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Cash Price	$1,701.05
Rate for Payer: Devoted Health Medicare	$1,149.36
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	$1,044.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$2,224.45
Rate for Payer: Humana Medicare	$1,044.87
Rate for Payer: Kaiser Permanente Commercial	$1,648.71
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,044.87
Rate for Payer: MDX Hawaii PPO	$2,538.49
Rate for Payer: Ohana Health Plan Medicaid	$1,149.36
Rate for Payer: Ohana Health Plan Medicare	$1,044.87
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,044.87
Rate for Payer: University Health Alliance Commercial	$4,035.20

Know your out-of-pocket cost for care.

All Charges