Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

E95812 EEG ñ Extended Monitoring ñ 41 to 60 Minutes

Facility

$1,575.00

Service Code	HCPCS 95812
Hospital Charge Code	12283595
Hospital Revenue Code	740
Min. Negotiated Rate	$92.69
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$92.69
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$181.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$92.69
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

E95812 EEG ñ Extended Monitoring ñ 41 to 60 Minutes

Facility

$1,575.00

Service Code	HCPCS 95812
Hospital Charge Code	12283595
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95812 EEG ñ Extended Monitoring ñ 41 to 60 Minutes

Professional

Both

$301.00

Service Code	HCPCS 95812
Hospital Charge Code	12283595
Hospital Revenue Code	986
Min. Negotiated Rate	$51.70
Max. Negotiated Rate	$514.76
Rate for Payer: AlohaCare Medicaid	$395.24
Rate for Payer: AlohaCare Medicare	$428.97
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$471.87
Rate for Payer: Hawaii Medical Service Association Medicare	$428.97
Rate for Payer: Hawaii Western Management Group Commercial	$51.70
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$514.76
Rate for Payer: Kaiser Permanente Medicaid	$514.76
Rate for Payer: Kaiser Permanente Medicare	$514.76
Rate for Payer: Ohana Health Plan Medicaid	$395.24
Rate for Payer: Ohana Health Plan Medicare	$428.97
Rate for Payer: UnitedHealthcare Medicaid	$395.24
Rate for Payer: UnitedHealthcare Medicare	$428.97

E95813 EEG ñ Extended Monitoring ñ 61 to 119 Minutes

Facility

$1,575.00

Service Code	HCPCS 95813
Hospital Charge Code	12283596
Hospital Revenue Code	740
Min. Negotiated Rate	$111.39
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$111.39
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$195.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$111.39
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

E95813 EEG ñ Extended Monitoring ñ 61 to 119 Minutes

Facility

$1,575.00

Service Code	HCPCS 95813
Hospital Charge Code	12283596
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95813 EEG ñ Extended Monitoring ñ 61 to 119 Minutes

Professional

Both

$301.00

Service Code	HCPCS 95813
Hospital Charge Code	12283596
Hospital Revenue Code	986
Min. Negotiated Rate	$107.72
Max. Negotiated Rate	$642.78
Rate for Payer: AlohaCare Medicaid	$498.26
Rate for Payer: AlohaCare Medicare	$535.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$589.22
Rate for Payer: Hawaii Medical Service Association Medicare	$535.65
Rate for Payer: Hawaii Western Management Group Commercial	$107.72
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$642.78
Rate for Payer: Kaiser Permanente Medicaid	$642.78
Rate for Payer: Kaiser Permanente Medicare	$642.78
Rate for Payer: Ohana Health Plan Medicaid	$498.26
Rate for Payer: Ohana Health Plan Medicare	$535.65
Rate for Payer: UnitedHealthcare Medicaid	$498.26
Rate for Payer: UnitedHealthcare Medicare	$535.65

E95816 EEG ñ Including Recording Awake and Drowsy

Facility

$1,537.00

Service Code	HCPCS 95816
Hospital Charge Code	12241748
Hospital Revenue Code	740
Min. Negotiated Rate	$84.17
Max. Negotiated Rate	$1,490.89
Rate for Payer: AlohaCare Medicaid	$768.50
Rate for Payer: AlohaCare Medicare	$768.50
Rate for Payer: Cash Price	$999.05
Rate for Payer: Cash Price	$999.05
Rate for Payer: Devoted Health Medicare	$845.35
Rate for Payer: Hawaii Medical Service Association ABD	$84.17
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$768.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$145.63
Rate for Payer: Hawaii Western Management Group Commercial	$1,460.15
Rate for Payer: Health Management Network Commercial	$1,306.45
Rate for Payer: Humana Medicare	$768.50
Rate for Payer: Kaiser Permanente Commercial	$1,383.30
Rate for Payer: Kaiser Permanente Medicaid	$783.87
Rate for Payer: Kaiser Permanente Medicare	$768.50
Rate for Payer: MDX Hawaii PPO	$1,490.89
Rate for Payer: Ohana Health Plan Medicaid	$768.50
Rate for Payer: Ohana Health Plan Medicare	$768.50
Rate for Payer: UnitedHealthcare Medicaid	$84.17
Rate for Payer: UnitedHealthcare Medicare	$768.50
Rate for Payer: University Health Alliance Commercial	$860.72

E95816 EEG ñ Including Recording Awake and Drowsy

Facility

$1,537.00

Service Code	HCPCS 95816
Hospital Charge Code	12241748
Hospital Revenue Code	740
Min. Negotiated Rate	$1,306.45
Max. Negotiated Rate	$1,490.89
Rate for Payer: Cash Price	$999.05
Rate for Payer: Health Management Network Commercial	$1,306.45
Rate for Payer: Kaiser Permanente Commercial	$1,383.30
Rate for Payer: MDX Hawaii PPO	$1,490.89

E95816 EEG ñ Including Recording Awake and Drowsy

Professional

Both

$301.00

Service Code	HCPCS 95816
Hospital Charge Code	12241748
Hospital Revenue Code	986
Min. Negotiated Rate	$105.68
Max. Negotiated Rate	$556.18
Rate for Payer: AlohaCare Medicaid	$445.92
Rate for Payer: AlohaCare Medicare	$463.48
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$509.83
Rate for Payer: Hawaii Medical Service Association Medicare	$463.48
Rate for Payer: Hawaii Western Management Group Commercial	$105.68
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$556.18
Rate for Payer: Kaiser Permanente Medicaid	$556.18
Rate for Payer: Kaiser Permanente Medicare	$556.18
Rate for Payer: Ohana Health Plan Medicaid	$445.92
Rate for Payer: Ohana Health Plan Medicare	$463.48
Rate for Payer: UnitedHealthcare Medicaid	$445.92
Rate for Payer: UnitedHealthcare Medicare	$463.48

E95819 EEG ñ Including Recording Awake and Asleep

Professional

Both

$301.00

Service Code	HCPCS 95819
Hospital Charge Code	12283597
Hospital Revenue Code	986
Min. Negotiated Rate	$114.84
Max. Negotiated Rate	$649.84
Rate for Payer: AlohaCare Medicaid	$514.57
Rate for Payer: AlohaCare Medicare	$541.53
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$595.68
Rate for Payer: Hawaii Medical Service Association Medicare	$541.53
Rate for Payer: Hawaii Western Management Group Commercial	$114.84
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$649.84
Rate for Payer: Kaiser Permanente Medicaid	$649.84
Rate for Payer: Kaiser Permanente Medicare	$649.84
Rate for Payer: Ohana Health Plan Medicaid	$514.57
Rate for Payer: Ohana Health Plan Medicare	$541.53
Rate for Payer: UnitedHealthcare Medicaid	$514.57
Rate for Payer: UnitedHealthcare Medicare	$541.53

E95819 EEG ñ Including Recording Awake and Asleep

Facility

$1,575.00

Service Code	HCPCS 95819
Hospital Charge Code	12283597
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95819 EEG ñ Including Recording Awake and Asleep

Facility

$1,575.00

Service Code	HCPCS 95819
Hospital Charge Code	12283597
Hospital Revenue Code	740
Min. Negotiated Rate	$65.74
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$65.74
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$174.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$65.74
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

E95822 EEG ñ Recording in Coma of Sleep ONLY

Facility

$1,575.00

Service Code	HCPCS 95822
Hospital Charge Code	12283598
Hospital Revenue Code	740
Min. Negotiated Rate	$107.20
Max. Negotiated Rate	$1,527.75
Rate for Payer: AlohaCare Medicaid	$787.50
Rate for Payer: AlohaCare Medicare	$787.50
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Devoted Health Medicare	$866.25
Rate for Payer: Hawaii Medical Service Association ABD	$107.20
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$787.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$169.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,496.25
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Humana Medicare	$787.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: Kaiser Permanente Medicare	$787.50
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: Ohana Health Plan Medicaid	$787.50
Rate for Payer: Ohana Health Plan Medicare	$787.50
Rate for Payer: UnitedHealthcare Medicaid	$107.20
Rate for Payer: UnitedHealthcare Medicare	$787.50
Rate for Payer: University Health Alliance Commercial	$882.00

E95822 EEG ñ Recording in Coma of Sleep ONLY

Professional

Both

$301.00

Service Code	HCPCS 95822
Hospital Charge Code	12283598
Hospital Revenue Code	986
Min. Negotiated Rate	$103.56
Max. Negotiated Rate	$601.75
Rate for Payer: AlohaCare Medicaid	$466.95
Rate for Payer: AlohaCare Medicare	$501.46
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Devoted Health Medicare	$551.61
Rate for Payer: Hawaii Medical Service Association Medicare	$501.46
Rate for Payer: Hawaii Western Management Group Commercial	$103.56
Rate for Payer: Health Management Network Commercial	$255.85
Rate for Payer: Kaiser Permanente Commercial	$601.75
Rate for Payer: Kaiser Permanente Medicaid	$601.75
Rate for Payer: Kaiser Permanente Medicare	$601.75
Rate for Payer: Ohana Health Plan Medicaid	$466.95
Rate for Payer: Ohana Health Plan Medicare	$501.46
Rate for Payer: UnitedHealthcare Medicaid	$466.95
Rate for Payer: UnitedHealthcare Medicare	$501.46

E95822 EEG ñ Recording in Coma of Sleep ONLY

Facility

$1,575.00

Service Code	HCPCS 95822
Hospital Charge Code	12283598
Hospital Revenue Code	740
Min. Negotiated Rate	$1,338.75
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$1,023.75
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: MDX Hawaii PPO	$1,527.75

E95824 EEG ñ Cerebral Death Evaluation ONLY

Facility

$2,151.00

Service Code	HCPCS 95824
Hospital Charge Code	12283599
Hospital Revenue Code	740
Min. Negotiated Rate	$1,828.35
Max. Negotiated Rate	$2,086.47
Rate for Payer: Cash Price	$1,398.15
Rate for Payer: Health Management Network Commercial	$1,828.35
Rate for Payer: Kaiser Permanente Commercial	$1,935.90
Rate for Payer: MDX Hawaii PPO	$2,086.47

E95824 EEG ñ Cerebral Death Evaluation ONLY

Professional

Both

$519.00

Service Code	HCPCS 95824
Hospital Charge Code	12283599
Hospital Revenue Code	986
Min. Negotiated Rate	$43.18
Max. Negotiated Rate	$441.15
Rate for Payer: AlohaCare Medicaid	$43.18
Rate for Payer: Cash Price	$337.35
Rate for Payer: Cash Price	$337.35
Rate for Payer: Hawaii Western Management Group Commercial	$49.16
Rate for Payer: Health Management Network Commercial	$441.15
Rate for Payer: Ohana Health Plan Medicaid	$43.18
Rate for Payer: UnitedHealthcare Medicaid	$43.18

E95824 EEG ñ Cerebral Death Evaluation ONLY

Facility

$2,151.00

Service Code	HCPCS 95824
Hospital Charge Code	12283599
Hospital Revenue Code	740
Min. Negotiated Rate	$14.68
Max. Negotiated Rate	$2,086.47
Rate for Payer: AlohaCare Medicaid	$1,075.50
Rate for Payer: AlohaCare Medicare	$1,075.50
Rate for Payer: Cash Price	$1,398.15
Rate for Payer: Cash Price	$1,398.15
Rate for Payer: Devoted Health Medicare	$1,183.05
Rate for Payer: Hawaii Medical Service Association ABD	$43.18
Rate for Payer: Hawaii Medical Service Association Commercial	$476.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.68
Rate for Payer: Hawaii Western Management Group Commercial	$2,043.45
Rate for Payer: Health Management Network Commercial	$1,828.35
Rate for Payer: Humana Medicare	$1,075.50
Rate for Payer: Kaiser Permanente Commercial	$1,935.90
Rate for Payer: Kaiser Permanente Medicaid	$1,097.01
Rate for Payer: Kaiser Permanente Medicare	$1,075.50
Rate for Payer: MDX Hawaii PPO	$2,086.47
Rate for Payer: Ohana Health Plan Medicaid	$1,075.50
Rate for Payer: Ohana Health Plan Medicare	$1,075.50
Rate for Payer: UnitedHealthcare Medicaid	$43.18
Rate for Payer: UnitedHealthcare Medicare	$1,075.50
Rate for Payer: University Health Alliance Commercial	$1,204.56

Each Additional 90472 - Admin Immunization charge

Facility

$142.00

Service Code	HCPCS 90472
Hospital Charge Code	12139186
Hospital Revenue Code	771
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$137.74
Rate for Payer: AlohaCare Medicaid	$71.00
Rate for Payer: AlohaCare Medicare	$71.00
Rate for Payer: Cash Price	$92.30
Rate for Payer: Cash Price	$92.30
Rate for Payer: Devoted Health Medicare	$78.10
Rate for Payer: Hawaii Medical Service Association ABD	$4.00
Rate for Payer: Hawaii Medical Service Association Medicare	$71.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6.28
Rate for Payer: Hawaii Western Management Group Commercial	$134.90
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Humana Medicare	$71.00
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: Kaiser Permanente Medicaid	$72.42
Rate for Payer: Kaiser Permanente Medicare	$71.00
Rate for Payer: MDX Hawaii PPO	$137.74
Rate for Payer: Ohana Health Plan Medicaid	$71.00
Rate for Payer: Ohana Health Plan Medicare	$71.00
Rate for Payer: UnitedHealthcare Medicaid	$4.00
Rate for Payer: UnitedHealthcare Medicare	$71.00
Rate for Payer: University Health Alliance Commercial	$79.52

Each Additional 90472 - Admin Immunization charge

Professional

Both

$45.00

Service Code	HCPCS 90472
Hospital Charge Code	12139186
Hospital Revenue Code	771
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$38.25
Rate for Payer: AlohaCare Medicare	$17.36
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$19.10
Rate for Payer: Hawaii Medical Service Association Medicare	$17.36
Rate for Payer: Hawaii Western Management Group Commercial	$9.00
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$20.83
Rate for Payer: Kaiser Permanente Medicaid	$20.83
Rate for Payer: Kaiser Permanente Medicare	$20.83
Rate for Payer: Ohana Health Plan Medicare	$17.36
Rate for Payer: UnitedHealthcare Medicare	$17.36

Each Additional 90472 - Admin Immunization charge

Facility

$142.00

Service Code	HCPCS 90472
Hospital Charge Code	12139186
Hospital Revenue Code	771
Min. Negotiated Rate	$120.70
Max. Negotiated Rate	$137.74
Rate for Payer: Cash Price	$92.30
Rate for Payer: Health Management Network Commercial	$120.70
Rate for Payer: Kaiser Permanente Commercial	$127.80
Rate for Payer: MDX Hawaii PPO	$137.74

Ear Irrigation/ Lavage POC

Professional

Both

$48.00

Service Code	HCPCS 69209
Hospital Charge Code	8196912
Hospital Revenue Code	521
Min. Negotiated Rate	$14.82
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$18.16
Rate for Payer: AlohaCare Medicare	$19.18
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Devoted Health Medicare	$21.10
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$14.82
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$23.02
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$18.16
Rate for Payer: Ohana Health Plan Medicare	$19.18
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46

Ear Irrigation/ Lavage POC

Facility

$48.00

Service Code	HCPCS 69209
Hospital Charge Code	8196912
Hospital Revenue Code	521
Min. Negotiated Rate	$18.16
Max. Negotiated Rate	$75.34
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$24.00
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Devoted Health Medicare	$26.40
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$24.00
Rate for Payer: Hawaii Western Management Group Commercial	$45.60
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$24.00
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$24.00
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$24.00
Rate for Payer: Ohana Health Plan Medicare	$24.00
Rate for Payer: UnitedHealthcare Medicaid	$18.16
Rate for Payer: UnitedHealthcare Medicare	$24.00
Rate for Payer: University Health Alliance Commercial	$26.88

Ear Irrigation/ Lavage POC

Facility

$48.00

Service Code	HCPCS 69209
Hospital Charge Code	8196912
Hospital Revenue Code	521
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$31.20
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$35,363.38

Service Code	MSDRG 147
Min. Negotiated Rate	$35,363.38
Max. Negotiated Rate	$35,363.38
Rate for Payer: Hawaii Medical Service Association Commercial	$35,363.38

Know your out-of-pocket cost for care.

All Charges