Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

US Hysterosonogram - Report

Professional

Both

$332.00

Service Code	HCPCS 76831 26
Hospital Charge Code	631132
Hospital Revenue Code	972
Min. Negotiated Rate	$35.55
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$77.59
Rate for Payer: AlohaCare Medicare	$35.55
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$39.10
Rate for Payer: Hawaii Medical Service Association Medicare	$35.55
Rate for Payer: Hawaii Western Management Group Commercial	$106.38
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$42.66
Rate for Payer: Kaiser Permanente Medicaid	$42.66
Rate for Payer: Kaiser Permanente Medicare	$42.66
Rate for Payer: Ohana Health Plan Medicaid	$77.59
Rate for Payer: Ohana Health Plan Medicare	$35.55
Rate for Payer: UnitedHealthcare Medicaid	$77.59
Rate for Payer: UnitedHealthcare Medicare	$35.55

US Intraoperative

Facility

$2,270.00

Service Code	HCPCS 76998
Hospital Charge Code	1169717
Hospital Revenue Code	402
Min. Negotiated Rate	$1,929.50
Max. Negotiated Rate	$2,201.90
Rate for Payer: Cash Price	$1,475.50
Rate for Payer: Health Management Network Commercial	$1,929.50
Rate for Payer: Kaiser Permanente Commercial	$2,043.00
Rate for Payer: MDX Hawaii PPO	$2,201.90

US Intraoperative

Facility

$2,270.00

Service Code	HCPCS 76998
Hospital Charge Code	1169717
Hospital Revenue Code	402
Min. Negotiated Rate	$93.99
Max. Negotiated Rate	$2,201.90
Rate for Payer: AlohaCare Medicaid	$1,135.00
Rate for Payer: AlohaCare Medicare	$1,135.00
Rate for Payer: Cash Price	$1,475.50
Rate for Payer: Cash Price	$1,475.50
Rate for Payer: Devoted Health Medicare	$1,248.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,135.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$93.99
Rate for Payer: Hawaii Western Management Group Commercial	$2,156.50
Rate for Payer: Health Management Network Commercial	$1,929.50
Rate for Payer: Humana Medicare	$1,135.00
Rate for Payer: Kaiser Permanente Commercial	$2,043.00
Rate for Payer: Kaiser Permanente Medicaid	$1,157.70
Rate for Payer: Kaiser Permanente Medicare	$1,135.00
Rate for Payer: MDX Hawaii PPO	$2,201.90
Rate for Payer: Ohana Health Plan Medicaid	$1,135.00
Rate for Payer: Ohana Health Plan Medicare	$1,135.00
Rate for Payer: UnitedHealthcare Medicare	$1,135.00
Rate for Payer: University Health Alliance Commercial	$1,271.20

US Intraoperative - Report

Professional

Both

$68.00

Service Code	HCPCS 76998 26
Hospital Charge Code	631209
Hospital Revenue Code	972
Min. Negotiated Rate	$48.39
Max. Negotiated Rate	$58.07
Rate for Payer: AlohaCare Medicare	$48.39
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Devoted Health Medicare	$53.23
Rate for Payer: Hawaii Medical Service Association Medicare	$48.39
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$58.07
Rate for Payer: Kaiser Permanente Medicaid	$58.07
Rate for Payer: Kaiser Permanente Medicare	$58.07
Rate for Payer: Ohana Health Plan Medicare	$48.39
Rate for Payer: UnitedHealthcare Medicare	$48.39

US Joint/Bursa Lw Int Arth/Asp/Inj Left

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	3148332
Hospital Revenue Code	361
Min. Negotiated Rate	$45.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$577.50
Rate for Payer: AlohaCare Medicare	$577.50
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Devoted Health Medicare	$635.25
Rate for Payer: Hawaii Medical Service Association Commercial	$392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$577.50
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Humana Medicare	$577.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$577.50
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: Ohana Health Plan Medicaid	$577.50
Rate for Payer: Ohana Health Plan Medicare	$577.50
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$577.50
Rate for Payer: University Health Alliance Commercial	$646.80

US Joint/Bursa Lw Int Arth/Asp/Inj Left

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	3148332
Hospital Revenue Code	361
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$750.75
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: MDX Hawaii PPO	$1,120.35

US Joint/Bursa Lw Int Arth/Asp/Inj Left - Report

Professional

Both

$427.00

Service Code	HCPCS 20604
Hospital Charge Code	3148334
Hospital Revenue Code	972
Min. Negotiated Rate	$39.16
Max. Negotiated Rate	$362.95
Rate for Payer: AlohaCare Medicaid	$45.64
Rate for Payer: AlohaCare Medicare	$39.16
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$43.08
Rate for Payer: Hawaii Medical Service Association ABD	$45.64
Rate for Payer: Hawaii Medical Service Association Commercial	$71.52
Rate for Payer: Hawaii Medical Service Association Medicare	$39.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.64
Rate for Payer: Hawaii Western Management Group Commercial	$78.26
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$46.99
Rate for Payer: Kaiser Permanente Medicaid	$46.99
Rate for Payer: Kaiser Permanente Medicare	$46.99
Rate for Payer: Ohana Health Plan Medicaid	$45.64
Rate for Payer: Ohana Health Plan Medicare	$39.16
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$39.16
Rate for Payer: University Health Alliance Commercial	$60.55

US Joint/Bursa Lw Int Arth/Asp/Inj Right

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	3148335
Hospital Revenue Code	361
Min. Negotiated Rate	$45.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$577.50
Rate for Payer: AlohaCare Medicare	$577.50
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Devoted Health Medicare	$635.25
Rate for Payer: Hawaii Medical Service Association Commercial	$392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$577.50
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Humana Medicare	$577.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$577.50
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: Ohana Health Plan Medicaid	$577.50
Rate for Payer: Ohana Health Plan Medicare	$577.50
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$577.50
Rate for Payer: University Health Alliance Commercial	$646.80

US Joint/Bursa Lw Int Arth/Asp/Inj Right

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	3148335
Hospital Revenue Code	361
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$750.75
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: MDX Hawaii PPO	$1,120.35

US Joint/Bursa Lw Int Arth/Asp/Inj Right - Report

Professional

Both

$427.00

Service Code	HCPCS 20604
Hospital Charge Code	3148337
Hospital Revenue Code	972
Min. Negotiated Rate	$39.16
Max. Negotiated Rate	$362.95
Rate for Payer: AlohaCare Medicaid	$45.64
Rate for Payer: AlohaCare Medicare	$39.16
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$43.08
Rate for Payer: Hawaii Medical Service Association ABD	$45.64
Rate for Payer: Hawaii Medical Service Association Commercial	$71.52
Rate for Payer: Hawaii Medical Service Association Medicare	$39.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.64
Rate for Payer: Hawaii Western Management Group Commercial	$78.26
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$46.99
Rate for Payer: Kaiser Permanente Medicaid	$46.99
Rate for Payer: Kaiser Permanente Medicare	$46.99
Rate for Payer: Ohana Health Plan Medicaid	$45.64
Rate for Payer: Ohana Health Plan Medicare	$39.16
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$39.16
Rate for Payer: University Health Alliance Commercial	$60.55

US Joint/Bursa Up Int Arth/Asp/Inj Left

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	2425353
Hospital Revenue Code	361
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$750.75
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: MDX Hawaii PPO	$1,120.35

US Joint/Bursa Up Int Arth/Asp/Inj Left

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	2425353
Hospital Revenue Code	361
Min. Negotiated Rate	$45.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$577.50
Rate for Payer: AlohaCare Medicare	$577.50
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Devoted Health Medicare	$635.25
Rate for Payer: Hawaii Medical Service Association Commercial	$392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$577.50
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Humana Medicare	$577.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$577.50
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: Ohana Health Plan Medicaid	$577.50
Rate for Payer: Ohana Health Plan Medicare	$577.50
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$577.50
Rate for Payer: University Health Alliance Commercial	$646.80

US Joint/Bursa Up Int Arth/Asp/Inj Left - Report

Professional

Both

$427.00

Service Code	HCPCS 20604
Hospital Charge Code	2425355
Hospital Revenue Code	972
Min. Negotiated Rate	$39.16
Max. Negotiated Rate	$362.95
Rate for Payer: AlohaCare Medicaid	$45.64
Rate for Payer: AlohaCare Medicare	$39.16
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$43.08
Rate for Payer: Hawaii Medical Service Association ABD	$45.64
Rate for Payer: Hawaii Medical Service Association Commercial	$71.52
Rate for Payer: Hawaii Medical Service Association Medicare	$39.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.64
Rate for Payer: Hawaii Western Management Group Commercial	$78.26
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$46.99
Rate for Payer: Kaiser Permanente Medicaid	$46.99
Rate for Payer: Kaiser Permanente Medicare	$46.99
Rate for Payer: Ohana Health Plan Medicaid	$45.64
Rate for Payer: Ohana Health Plan Medicare	$39.16
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$39.16
Rate for Payer: University Health Alliance Commercial	$60.55

US Joint/Bursa Up Int Arth/Asp/Inj Right

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	2425356
Hospital Revenue Code	361
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$750.75
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: MDX Hawaii PPO	$1,120.35

US Joint/Bursa Up Int Arth/Asp/Inj Right

Facility

$1,155.00

Service Code	HCPCS 20604
Hospital Charge Code	2425356
Hospital Revenue Code	361
Min. Negotiated Rate	$45.64
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$577.50
Rate for Payer: AlohaCare Medicare	$577.50
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Devoted Health Medicare	$635.25
Rate for Payer: Hawaii Medical Service Association Commercial	$392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$577.50
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Humana Medicare	$577.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$577.50
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: Ohana Health Plan Medicaid	$577.50
Rate for Payer: Ohana Health Plan Medicare	$577.50
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$577.50
Rate for Payer: University Health Alliance Commercial	$646.80

US Joint/Bursa Up Int Arth/Asp/Inj Right - Report

Professional

Both

$427.00

Service Code	HCPCS 20604
Hospital Charge Code	2425358
Hospital Revenue Code	972
Min. Negotiated Rate	$39.16
Max. Negotiated Rate	$362.95
Rate for Payer: AlohaCare Medicaid	$45.64
Rate for Payer: AlohaCare Medicare	$39.16
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Devoted Health Medicare	$43.08
Rate for Payer: Hawaii Medical Service Association ABD	$45.64
Rate for Payer: Hawaii Medical Service Association Commercial	$71.52
Rate for Payer: Hawaii Medical Service Association Medicare	$39.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.64
Rate for Payer: Hawaii Western Management Group Commercial	$78.26
Rate for Payer: Health Management Network Commercial	$362.95
Rate for Payer: Kaiser Permanente Commercial	$46.99
Rate for Payer: Kaiser Permanente Medicaid	$46.99
Rate for Payer: Kaiser Permanente Medicare	$46.99
Rate for Payer: Ohana Health Plan Medicaid	$45.64
Rate for Payer: Ohana Health Plan Medicare	$39.16
Rate for Payer: UnitedHealthcare Medicaid	$45.64
Rate for Payer: UnitedHealthcare Medicare	$39.16
Rate for Payer: University Health Alliance Commercial	$60.55

US Kidney Transplant w/ Doppler

Facility

$1,827.00

Service Code	HCPCS 76776
Hospital Charge Code	1169749
Hospital Revenue Code	402
Min. Negotiated Rate	$67.84
Max. Negotiated Rate	$1,772.19
Rate for Payer: AlohaCare Medicaid	$913.50
Rate for Payer: AlohaCare Medicare	$913.50
Rate for Payer: Cash Price	$1,187.55
Rate for Payer: Cash Price	$1,187.55
Rate for Payer: Devoted Health Medicare	$1,004.85
Rate for Payer: Hawaii Medical Service Association ABD	$67.84
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$913.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$71.23
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$1,552.95
Rate for Payer: Humana Medicare	$913.50
Rate for Payer: Kaiser Permanente Commercial	$1,644.30
Rate for Payer: Kaiser Permanente Medicaid	$931.77
Rate for Payer: Kaiser Permanente Medicare	$913.50
Rate for Payer: MDX Hawaii PPO	$1,772.19
Rate for Payer: Ohana Health Plan Medicaid	$913.50
Rate for Payer: Ohana Health Plan Medicare	$913.50
Rate for Payer: UnitedHealthcare Medicaid	$67.84
Rate for Payer: UnitedHealthcare Medicare	$913.50
Rate for Payer: University Health Alliance Commercial	$281.14

US Kidney Transplant w/ Doppler

Facility

$1,827.00

Service Code	HCPCS 76776
Hospital Charge Code	1169749
Hospital Revenue Code	402
Min. Negotiated Rate	$1,552.95
Max. Negotiated Rate	$1,772.19
Rate for Payer: Cash Price	$1,187.55
Rate for Payer: Health Management Network Commercial	$1,552.95
Rate for Payer: Kaiser Permanente Commercial	$1,644.30
Rate for Payer: MDX Hawaii PPO	$1,772.19

US Kidney Transplant w/ Doppler - Report

Professional

Both

$246.00

Service Code	HCPCS 76776 26
Hospital Charge Code	631072
Hospital Revenue Code	972
Min. Negotiated Rate	$35.36
Max. Negotiated Rate	$209.10
Rate for Payer: AlohaCare Medicaid	$98.47
Rate for Payer: AlohaCare Medicare	$35.36
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Devoted Health Medicare	$38.90
Rate for Payer: Hawaii Medical Service Association Medicare	$35.36
Rate for Payer: Hawaii Western Management Group Commercial	$175.85
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$42.43
Rate for Payer: Kaiser Permanente Medicaid	$42.43
Rate for Payer: Kaiser Permanente Medicare	$42.43
Rate for Payer: Ohana Health Plan Medicaid	$98.47
Rate for Payer: Ohana Health Plan Medicare	$35.36
Rate for Payer: UnitedHealthcare Medicaid	$98.47
Rate for Payer: UnitedHealthcare Medicare	$35.36

US Lower Ext Arterial Duplex Bilateral

Facility

$1,045.00

Service Code	HCPCS 93925
Hospital Charge Code	1169759
Hospital Revenue Code	921
Min. Negotiated Rate	$888.25
Max. Negotiated Rate	$1,013.65
Rate for Payer: Cash Price	$679.25
Rate for Payer: Health Management Network Commercial	$888.25
Rate for Payer: Kaiser Permanente Commercial	$940.50
Rate for Payer: MDX Hawaii PPO	$1,013.65

US Lower Ext Arterial Duplex Bilateral

Facility

$1,045.00

Service Code	HCPCS 93925
Hospital Charge Code	1169759
Hospital Revenue Code	921
Min. Negotiated Rate	$173.10
Max. Negotiated Rate	$1,013.65
Rate for Payer: AlohaCare Medicaid	$522.50
Rate for Payer: AlohaCare Medicare	$522.50
Rate for Payer: Cash Price	$679.25
Rate for Payer: Cash Price	$679.25
Rate for Payer: Devoted Health Medicare	$574.75
Rate for Payer: Hawaii Medical Service Association ABD	$173.10
Rate for Payer: Hawaii Medical Service Association Commercial	$304.71
Rate for Payer: Hawaii Medical Service Association Medicare	$522.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$206.69
Rate for Payer: Hawaii Western Management Group Commercial	$992.75
Rate for Payer: Health Management Network Commercial	$888.25
Rate for Payer: Humana Medicare	$522.50
Rate for Payer: Kaiser Permanente Commercial	$940.50
Rate for Payer: Kaiser Permanente Medicaid	$532.95
Rate for Payer: Kaiser Permanente Medicare	$522.50
Rate for Payer: MDX Hawaii PPO	$1,013.65
Rate for Payer: Ohana Health Plan Medicaid	$522.50
Rate for Payer: Ohana Health Plan Medicare	$522.50
Rate for Payer: UnitedHealthcare Medicaid	$173.10
Rate for Payer: UnitedHealthcare Medicare	$522.50
Rate for Payer: University Health Alliance Commercial	$585.20

US Lower Ext Arterial Duplex Bilateral - Report

Professional

Both

$332.00

Service Code	HCPCS 93925 26
Hospital Charge Code	631052
Hospital Revenue Code	972
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$282.20
Rate for Payer: AlohaCare Medicaid	$269.64
Rate for Payer: AlohaCare Medicare	$36.90
Rate for Payer: Cash Price	$215.80
Rate for Payer: Cash Price	$215.80
Rate for Payer: Devoted Health Medicare	$40.59
Rate for Payer: Hawaii Medical Service Association Medicare	$36.90
Rate for Payer: Hawaii Western Management Group Commercial	$142.83
Rate for Payer: Health Management Network Commercial	$282.20
Rate for Payer: Kaiser Permanente Commercial	$44.28
Rate for Payer: Kaiser Permanente Medicaid	$44.28
Rate for Payer: Kaiser Permanente Medicare	$44.28
Rate for Payer: Ohana Health Plan Medicaid	$269.64
Rate for Payer: Ohana Health Plan Medicare	$36.90
Rate for Payer: UnitedHealthcare Medicaid	$269.64
Rate for Payer: UnitedHealthcare Medicare	$36.90

US Lower Ext Arterial Duplex Left

Facility

$740.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	1169761
Hospital Revenue Code	921
Min. Negotiated Rate	$629.00
Max. Negotiated Rate	$717.80
Rate for Payer: Cash Price	$481.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: MDX Hawaii PPO	$717.80

US Lower Ext Arterial Duplex Left

Facility

$740.00

Service Code	HCPCS 93926 LT
Hospital Charge Code	1169761
Hospital Revenue Code	921
Min. Negotiated Rate	$103.46
Max. Negotiated Rate	$717.80
Rate for Payer: AlohaCare Medicaid	$370.00
Rate for Payer: AlohaCare Medicare	$370.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Cash Price	$481.00
Rate for Payer: Devoted Health Medicare	$407.00
Rate for Payer: Hawaii Medical Service Association ABD	$103.46
Rate for Payer: Hawaii Medical Service Association Medicare	$370.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123.54
Rate for Payer: Hawaii Western Management Group Commercial	$703.00
Rate for Payer: Health Management Network Commercial	$629.00
Rate for Payer: Humana Medicare	$370.00
Rate for Payer: Kaiser Permanente Commercial	$666.00
Rate for Payer: Kaiser Permanente Medicaid	$377.40
Rate for Payer: Kaiser Permanente Medicare	$370.00
Rate for Payer: MDX Hawaii PPO	$717.80
Rate for Payer: Ohana Health Plan Medicaid	$370.00
Rate for Payer: Ohana Health Plan Medicare	$370.00
Rate for Payer: UnitedHealthcare Medicaid	$103.46
Rate for Payer: UnitedHealthcare Medicare	$370.00
Rate for Payer: University Health Alliance Commercial	$414.40

US Lower Ext Arterial Duplex Left - Report

Professional

Both

$145.00

Service Code	HCPCS 93926 26,LT
Hospital Charge Code	631050
Hospital Revenue Code	972
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$161.18
Rate for Payer: AlohaCare Medicaid	$161.18
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$131.13
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$161.18
Rate for Payer: UnitedHealthcare Medicaid	$161.18

Know your out-of-pocket cost for care.

All Charges