Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

.Antibody Titer to BBH FSI

Facility

$1,301.00

Service Code	HCPCS 86886
Hospital Charge Code	8117848
Hospital Revenue Code	302
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$1,261.97
Rate for Payer: AlohaCare Medicaid	$650.50
Rate for Payer: AlohaCare Medicare	$650.50
Rate for Payer: Cash Price	$845.65
Rate for Payer: Cash Price	$845.65
Rate for Payer: Devoted Health Medicare	$715.55
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$650.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$1,105.85
Rate for Payer: Humana Medicare	$650.50
Rate for Payer: Kaiser Permanente Commercial	$1,170.90
Rate for Payer: Kaiser Permanente Medicaid	$663.51
Rate for Payer: Kaiser Permanente Medicare	$650.50
Rate for Payer: MDX Hawaii PPO	$1,261.97
Rate for Payer: Ohana Health Plan Medicaid	$650.50
Rate for Payer: Ohana Health Plan Medicare	$650.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$650.50
Rate for Payer: University Health Alliance Commercial	$13.38

Anti-Centromere IgG Ab FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8117849
Hospital Revenue Code	302
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

Anti-Centromere IgG Ab FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8117849
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$46.36

Anti-CMV IgG and IgM FSI

Facility

$242.00

Service Code	HCPCS 86644
Hospital Charge Code	8521879
Hospital Revenue Code	300
Min. Negotiated Rate	$205.70
Max. Negotiated Rate	$234.74
Rate for Payer: Cash Price	$157.30
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: MDX Hawaii PPO	$234.74

Anti-CMV IgG and IgM FSI

Facility

$242.00

Service Code	HCPCS 86644
Hospital Charge Code	8521879
Hospital Revenue Code	300
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$234.74
Rate for Payer: AlohaCare Medicaid	$121.00
Rate for Payer: AlohaCare Medicare	$121.00
Rate for Payer: Cash Price	$157.30
Rate for Payer: Cash Price	$157.30
Rate for Payer: Devoted Health Medicare	$133.10
Rate for Payer: Hawaii Medical Service Association ABD	$19.89
Rate for Payer: Hawaii Medical Service Association Commercial	$17.99
Rate for Payer: Hawaii Medical Service Association Medicare	$121.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.39
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Humana Medicare	$121.00
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: Kaiser Permanente Medicaid	$123.42
Rate for Payer: Kaiser Permanente Medicare	$121.00
Rate for Payer: MDX Hawaii PPO	$234.74
Rate for Payer: Ohana Health Plan Medicaid	$121.00
Rate for Payer: Ohana Health Plan Medicare	$121.00
Rate for Payer: UnitedHealthcare Medicaid	$19.89
Rate for Payer: UnitedHealthcare Medicare	$121.00
Rate for Payer: University Health Alliance Commercial	$37.20

Anti Cyclic Citrullinated Peptide Ab IgG Anti-CCP FSI

Facility

$148.00

Service Code	HCPCS 86200
Hospital Charge Code	8117843
Hospital Revenue Code	302
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$143.56
Rate for Payer: AlohaCare Medicaid	$74.00
Rate for Payer: AlohaCare Medicare	$74.00
Rate for Payer: Cash Price	$96.20
Rate for Payer: Cash Price	$96.20
Rate for Payer: Devoted Health Medicare	$81.40
Rate for Payer: Hawaii Medical Service Association ABD	$12.66
Rate for Payer: Hawaii Medical Service Association Commercial	$16.19
Rate for Payer: Hawaii Medical Service Association Medicare	$74.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.95
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Humana Medicare	$74.00
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: Kaiser Permanente Medicare	$74.00
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: Ohana Health Plan Medicaid	$74.00
Rate for Payer: Ohana Health Plan Medicare	$74.00
Rate for Payer: UnitedHealthcare Medicaid	$12.66
Rate for Payer: UnitedHealthcare Medicare	$74.00
Rate for Payer: University Health Alliance Commercial	$33.47

Anti Cyclic Citrullinated Peptide Ab IgG Anti-CCP FSI

Facility

$148.00

Service Code	HCPCS 86200
Hospital Charge Code	8117843
Hospital Revenue Code	302
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$96.20
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: MDX Hawaii PPO	$143.56

Anti-DNA DS Ab FSI

Facility

$157.00

Service Code	HCPCS 86225
Hospital Charge Code	8117850
Hospital Revenue Code	302
Min. Negotiated Rate	$13.74
Max. Negotiated Rate	$152.29
Rate for Payer: AlohaCare Medicaid	$78.50
Rate for Payer: AlohaCare Medicare	$78.50
Rate for Payer: Cash Price	$102.05
Rate for Payer: Cash Price	$102.05
Rate for Payer: Devoted Health Medicare	$86.35
Rate for Payer: Hawaii Medical Service Association ABD	$18.99
Rate for Payer: Hawaii Medical Service Association Commercial	$17.18
Rate for Payer: Hawaii Medical Service Association Medicare	$78.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.94
Rate for Payer: Hawaii Western Management Group Commercial	$13.74
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Humana Medicare	$78.50
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: Kaiser Permanente Medicaid	$80.07
Rate for Payer: Kaiser Permanente Medicare	$78.50
Rate for Payer: MDX Hawaii PPO	$152.29
Rate for Payer: Ohana Health Plan Medicaid	$78.50
Rate for Payer: Ohana Health Plan Medicare	$78.50
Rate for Payer: UnitedHealthcare Medicaid	$18.99
Rate for Payer: UnitedHealthcare Medicare	$78.50
Rate for Payer: University Health Alliance Commercial	$35.52

Anti-DNA DS Ab FSI

Facility

$157.00

Service Code	HCPCS 86225
Hospital Charge Code	8117850
Hospital Revenue Code	302
Min. Negotiated Rate	$133.45
Max. Negotiated Rate	$152.29
Rate for Payer: Cash Price	$102.05
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: MDX Hawaii PPO	$152.29

Anti ENA (Smith, Smith/RNP) Panel FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8117844
Hospital Revenue Code	302
Min. Negotiated Rate	$174.25
Max. Negotiated Rate	$198.85
Rate for Payer: Cash Price	$133.25
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: MDX Hawaii PPO	$198.85

Anti ENA (Smith, Smith/RNP) Panel FSI

Facility

$205.00

Service Code	HCPCS 86235
Hospital Charge Code	8117844
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
Max. Negotiated Rate	$198.85
Rate for Payer: AlohaCare Medicaid	$102.50
Rate for Payer: AlohaCare Medicare	$102.50
Rate for Payer: Cash Price	$133.25
Rate for Payer: Cash Price	$133.25
Rate for Payer: Devoted Health Medicare	$112.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$102.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$174.25
Rate for Payer: Humana Medicare	$102.50
Rate for Payer: Kaiser Permanente Commercial	$184.50
Rate for Payer: Kaiser Permanente Medicaid	$104.55
Rate for Payer: Kaiser Permanente Medicare	$102.50
Rate for Payer: MDX Hawaii PPO	$198.85
Rate for Payer: Ohana Health Plan Medicaid	$102.50
Rate for Payer: Ohana Health Plan Medicare	$102.50
Rate for Payer: UnitedHealthcare Medicaid	$24.78
Rate for Payer: UnitedHealthcare Medicare	$102.50
Rate for Payer: University Health Alliance Commercial	$46.36

Anti Mullerian Hormone, Female FSI

Facility

$236.00

Service Code	HCPCS 83520
Hospital Charge Code	8117845
Hospital Revenue Code	300
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$153.40
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

Anti Mullerian Hormone, Female FSI

Facility

$236.00

Service Code	HCPCS 83520
Hospital Charge Code	8117845
Hospital Revenue Code	300
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$118.00
Rate for Payer: Cash Price	$153.40
Rate for Payer: Cash Price	$153.40
Rate for Payer: Devoted Health Medicare	$129.80
Rate for Payer: Hawaii Medical Service Association ABD	$17.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21.59
Rate for Payer: Hawaii Medical Service Association Medicare	$118.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.27
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$118.00
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$118.00
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$118.00
Rate for Payer: Ohana Health Plan Medicare	$118.00
Rate for Payer: UnitedHealthcare Medicaid	$17.89
Rate for Payer: UnitedHealthcare Medicare	$118.00
Rate for Payer: University Health Alliance Commercial	$33.47

Anti Neutrophilic Cytoplasmic Antibody ANCA FSI

Facility

$87.00

Service Code	HCPCS 86036
Hospital Charge Code	8117846
Hospital Revenue Code	300
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$43.50
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$47.85
Rate for Payer: Hawaii Medical Service Association ABD	$16.66
Rate for Payer: Hawaii Medical Service Association Commercial	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$43.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.49
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$43.50
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$43.50
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$43.50
Rate for Payer: Ohana Health Plan Medicare	$43.50
Rate for Payer: UnitedHealthcare Medicaid	$7.23
Rate for Payer: UnitedHealthcare Medicare	$43.50
Rate for Payer: University Health Alliance Commercial	$48.72

Anti Neutrophilic Cytoplasmic Antibody ANCA FSI

Facility

$87.00

Service Code	HCPCS 86036
Hospital Charge Code	8117846
Hospital Revenue Code	300
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

Anti-Parietal Cell AB FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8404549
Hospital Revenue Code	302
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$678.03
Rate for Payer: AlohaCare Medicaid	$349.50
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$356.49
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$29.82

Anti-Parietal Cell AB FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8404549
Hospital Revenue Code	302
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

ANTI-ROTATION SCREW, 5.0 MM X 100 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970885
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 100 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970885
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 60 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970888
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 60 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970888
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 65 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970886
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 65 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970886
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 70 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970887
Hospital Revenue Code	278
Min. Negotiated Rate	$896.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: University Health Alliance Commercial	$896.00

ANTI-ROTATION SCREW, 5.0 MM X 70 MM

Facility

$1,600.00

Service Code	HCPCS C1713
Hospital Charge Code	12970887
Hospital Revenue Code	278
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,552.00
Rate for Payer: AlohaCare Medicaid	$800.00
Rate for Payer: AlohaCare Medicare	$800.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Devoted Health Medicare	$880.00
Rate for Payer: Hawaii Medical Service Association Medicare	$800.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.00
Rate for Payer: Health Management Network Commercial	$1,360.00
Rate for Payer: Humana Medicare	$800.00
Rate for Payer: Kaiser Permanente Commercial	$1,440.00
Rate for Payer: Kaiser Permanente Medicaid	$816.00
Rate for Payer: Kaiser Permanente Medicare	$800.00
Rate for Payer: MDX Hawaii PPO	$1,552.00
Rate for Payer: Ohana Health Plan Medicaid	$800.00
Rate for Payer: Ohana Health Plan Medicare	$800.00
Rate for Payer: UnitedHealthcare Medicare	$800.00
Rate for Payer: University Health Alliance Commercial	$896.00

Know your out-of-pocket cost for care.

All Charges