Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

FFP 4 Units FSI

Facility

$339.00

Service Code	HCPCS 86927
Hospital Charge Code	11641973
Hospital Revenue Code	305
Min. Negotiated Rate	$288.15
Max. Negotiated Rate	$328.83
Rate for Payer: Cash Price	$220.35
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: MDX Hawaii PPO	$328.83

FFP 4 Units FSI

Facility

$339.00

Service Code	HCPCS 86927
Hospital Charge Code	11641973
Hospital Revenue Code	305
Min. Negotiated Rate	$5.35
Max. Negotiated Rate	$328.83
Rate for Payer: AlohaCare Medicaid	$169.50
Rate for Payer: AlohaCare Medicare	$169.50
Rate for Payer: Cash Price	$220.35
Rate for Payer: Cash Price	$220.35
Rate for Payer: Devoted Health Medicare	$186.45
Rate for Payer: Hawaii Medical Service Association Commercial	$217.57
Rate for Payer: Hawaii Medical Service Association Medicare	$169.50
Rate for Payer: Hawaii Western Management Group Commercial	$174.06
Rate for Payer: Health Management Network Commercial	$288.15
Rate for Payer: Humana Medicare	$169.50
Rate for Payer: Kaiser Permanente Commercial	$305.10
Rate for Payer: Kaiser Permanente Medicaid	$172.89
Rate for Payer: Kaiser Permanente Medicare	$169.50
Rate for Payer: MDX Hawaii PPO	$328.83
Rate for Payer: Ohana Health Plan Medicaid	$169.50
Rate for Payer: Ohana Health Plan Medicare	$169.50
Rate for Payer: UnitedHealthcare Medicaid	$5.35
Rate for Payer: UnitedHealthcare Medicare	$169.50
Rate for Payer: University Health Alliance Commercial	$189.84

Fibrin Degradation Products FDP FSI

Facility

$97.00

Service Code	HCPCS 85362
Hospital Charge Code	8228867
Hospital Revenue Code	305
Min. Negotiated Rate	$82.45
Max. Negotiated Rate	$94.09
Rate for Payer: Cash Price	$63.05
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: MDX Hawaii PPO	$94.09

Fibrin Degradation Products FDP FSI

Facility

$97.00

Service Code	HCPCS 85362
Hospital Charge Code	8228867
Hospital Revenue Code	305
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$94.09
Rate for Payer: AlohaCare Medicaid	$48.50
Rate for Payer: AlohaCare Medicare	$48.50
Rate for Payer: Cash Price	$63.05
Rate for Payer: Cash Price	$63.05
Rate for Payer: Devoted Health Medicare	$53.35
Rate for Payer: Hawaii Medical Service Association ABD	$9.52
Rate for Payer: Hawaii Medical Service Association Commercial	$8.61
Rate for Payer: Hawaii Medical Service Association Medicare	$48.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10.00
Rate for Payer: Hawaii Western Management Group Commercial	$6.89
Rate for Payer: Health Management Network Commercial	$82.45
Rate for Payer: Humana Medicare	$48.50
Rate for Payer: Kaiser Permanente Commercial	$87.30
Rate for Payer: Kaiser Permanente Medicaid	$49.47
Rate for Payer: Kaiser Permanente Medicare	$48.50
Rate for Payer: MDX Hawaii PPO	$94.09
Rate for Payer: Ohana Health Plan Medicaid	$48.50
Rate for Payer: Ohana Health Plan Medicare	$48.50
Rate for Payer: UnitedHealthcare Medicaid	$9.52
Rate for Payer: UnitedHealthcare Medicare	$48.50
Rate for Payer: University Health Alliance Commercial	$17.80

Fibrinogen FSI

Facility

$126.00

Service Code	HCPCS 85384
Hospital Charge Code	8117911
Hospital Revenue Code	305
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$81.90
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: MDX Hawaii PPO	$122.22

Fibrinogen FSI

Facility

$126.00

Service Code	HCPCS 85384
Hospital Charge Code	8117911
Hospital Revenue Code	305
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$122.22
Rate for Payer: AlohaCare Medicaid	$63.00
Rate for Payer: AlohaCare Medicare	$63.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Hawaii Medical Service Association ABD	$11.74
Rate for Payer: Hawaii Medical Service Association Commercial	$12.15
Rate for Payer: Hawaii Medical Service Association Medicare	$63.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.33
Rate for Payer: Hawaii Western Management Group Commercial	$9.72
Rate for Payer: Health Management Network Commercial	$107.10
Rate for Payer: Humana Medicare	$63.00
Rate for Payer: Kaiser Permanente Commercial	$113.40
Rate for Payer: Kaiser Permanente Medicaid	$64.26
Rate for Payer: Kaiser Permanente Medicare	$63.00
Rate for Payer: MDX Hawaii PPO	$122.22
Rate for Payer: Ohana Health Plan Medicaid	$63.00
Rate for Payer: Ohana Health Plan Medicare	$63.00
Rate for Payer: UnitedHealthcare Medicaid	$11.74
Rate for Payer: UnitedHealthcare Medicare	$63.00
Rate for Payer: University Health Alliance Commercial	$21.96

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (DIP + PIP extension; L)

Facility

$195.00

Service Code	HCPCS L3925
Hospital Charge Code	13358970
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$97.50
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Devoted Health Medicare	$107.25
Rate for Payer: Hawaii Medical Service Association Medicare	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$97.50
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$97.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$97.50
Rate for Payer: Ohana Health Plan Medicare	$97.50
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$97.50
Rate for Payer: University Health Alliance Commercial	$109.20

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (DIP + PIP extension; L)

Facility

$195.00

Service Code	HCPCS L3925
Hospital Charge Code	13358970
Hospital Revenue Code	274
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$126.75
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: University Health Alliance Commercial	$109.20

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (DIP + PIP extension; M)

Facility

$195.00

Service Code	HCPCS L3925
Hospital Charge Code	13358969
Hospital Revenue Code	274
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$126.75
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: University Health Alliance Commercial	$109.20

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (DIP + PIP extension; M)

Facility

$195.00

Service Code	HCPCS L3925
Hospital Charge Code	13358969
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$97.50
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Devoted Health Medicare	$107.25
Rate for Payer: Hawaii Medical Service Association Medicare	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$97.50
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$97.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$97.50
Rate for Payer: Ohana Health Plan Medicare	$97.50
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$97.50
Rate for Payer: University Health Alliance Commercial	$109.20

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (DIP + PIP extension; S)

Facility

$195.00

Service Code	HCPCS L3925
Hospital Charge Code	13358961
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$189.15
Rate for Payer: AlohaCare Medicaid	$97.50
Rate for Payer: AlohaCare Medicare	$97.50
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Devoted Health Medicare	$107.25
Rate for Payer: Hawaii Medical Service Association Medicare	$97.50
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Humana Medicare	$97.50
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: Kaiser Permanente Medicare	$97.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: Ohana Health Plan Medicaid	$97.50
Rate for Payer: Ohana Health Plan Medicare	$97.50
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$97.50
Rate for Payer: University Health Alliance Commercial	$109.20

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (DIP + PIP extension; S)

Facility

$195.00

Service Code	HCPCS L3925
Hospital Charge Code	13358961
Hospital Revenue Code	274
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$126.75
Rate for Payer: Hawaii Western Management Group Commercial	$136.50
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$175.50
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: University Health Alliance Commercial	$109.20

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; A)

Facility

$130.00

Service Code	HCPCS L3925
Hospital Charge Code	13358971
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$126.10
Rate for Payer: AlohaCare Medicaid	$65.00
Rate for Payer: AlohaCare Medicare	$65.00
Rate for Payer: Cash Price	$84.50
Rate for Payer: Cash Price	$84.50
Rate for Payer: Devoted Health Medicare	$71.50
Rate for Payer: Hawaii Medical Service Association Medicare	$65.00
Rate for Payer: Hawaii Western Management Group Commercial	$91.00
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Humana Medicare	$65.00
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: Kaiser Permanente Medicaid	$66.30
Rate for Payer: Kaiser Permanente Medicare	$65.00
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: Ohana Health Plan Medicaid	$65.00
Rate for Payer: Ohana Health Plan Medicare	$65.00
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$65.00
Rate for Payer: University Health Alliance Commercial	$72.80

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; A)

Facility

$130.00

Service Code	HCPCS L3925
Hospital Charge Code	13358971
Hospital Revenue Code	274
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$84.50
Rate for Payer: Hawaii Western Management Group Commercial	$91.00
Rate for Payer: Health Management Network Commercial	$110.50
Rate for Payer: Kaiser Permanente Commercial	$117.00
Rate for Payer: MDX Hawaii PPO	$126.10
Rate for Payer: University Health Alliance Commercial	$72.80

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; AA)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358966
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$68.00
Rate for Payer: Cash Price	$88.40
Rate for Payer: Cash Price	$88.40
Rate for Payer: Devoted Health Medicare	$74.80
Rate for Payer: Hawaii Medical Service Association Medicare	$68.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$68.00
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$68.00
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$68.00
Rate for Payer: Ohana Health Plan Medicare	$68.00
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$68.00
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; AA)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358966
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$88.40
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; B)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358967
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$88.40
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; B)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358967
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$68.00
Rate for Payer: Cash Price	$88.40
Rate for Payer: Cash Price	$88.40
Rate for Payer: Devoted Health Medicare	$74.80
Rate for Payer: Hawaii Medical Service Association Medicare	$68.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$68.00
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$68.00
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$68.00
Rate for Payer: Ohana Health Plan Medicare	$68.00
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$68.00
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; C)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358972
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$88.40
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; C)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358972
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$68.00
Rate for Payer: Cash Price	$88.40
Rate for Payer: Cash Price	$88.40
Rate for Payer: Devoted Health Medicare	$74.80
Rate for Payer: Hawaii Medical Service Association Medicare	$68.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$68.00
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$68.00
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$68.00
Rate for Payer: Ohana Health Plan Medicare	$68.00
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$68.00
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; D)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358968
Hospital Revenue Code	274
Min. Negotiated Rate	$51.93
Max. Negotiated Rate	$131.92
Rate for Payer: AlohaCare Medicaid	$68.00
Rate for Payer: AlohaCare Medicare	$68.00
Rate for Payer: Cash Price	$88.40
Rate for Payer: Cash Price	$88.40
Rate for Payer: Devoted Health Medicare	$74.80
Rate for Payer: Hawaii Medical Service Association Medicare	$68.00
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Humana Medicare	$68.00
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: Kaiser Permanente Medicaid	$69.36
Rate for Payer: Kaiser Permanente Medicare	$68.00
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: Ohana Health Plan Medicaid	$68.00
Rate for Payer: Ohana Health Plan Medicare	$68.00
Rate for Payer: UnitedHealthcare Medicaid	$51.93
Rate for Payer: UnitedHealthcare Medicare	$68.00
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, Joint/spring, Prefab, OTS (PIP extension; D)

Facility

$136.00

Service Code	HCPCS L3925
Hospital Charge Code	13358968
Hospital Revenue Code	274
Min. Negotiated Rate	$76.16
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$88.40
Rate for Payer: Hawaii Western Management Group Commercial	$95.20
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$122.40
Rate for Payer: MDX Hawaii PPO	$131.92
Rate for Payer: University Health Alliance Commercial	$76.16

Finger Orthosis, DIP, PIP, w/o Joint/spring, Prefab, OTS (oval - 8; 10)

Facility

$66.00

Service Code	HCPCS L3927
Hospital Charge Code	13369811
Hospital Revenue Code	274
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Western Management Group Commercial	$46.20
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$36.96

Finger Orthosis, DIP, PIP, w/o Joint/spring, Prefab, OTS (oval - 8; 10)

Facility

$66.00

Service Code	HCPCS L3927
Hospital Charge Code	13369811
Hospital Revenue Code	274
Min. Negotiated Rate	$36.96
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$46.20
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: University Health Alliance Commercial	$36.96

Finger Orthosis, DIP, PIP, w/o Joint/spring, Prefab, OTS (oval - 8; 11)

Facility

$66.00

Service Code	HCPCS L3927
Hospital Charge Code	13371696
Hospital Revenue Code	274
Min. Negotiated Rate	$36.96
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Hawaii Western Management Group Commercial	$46.20
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: University Health Alliance Commercial	$36.96

Know your out-of-pocket cost for care.

All Charges