Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

US Retroperitoneal Complete

Facility

$758.00

Service Code	HCPCS 76770
Hospital Charge Code	1169867
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Retroperitoneal Complete

Facility

$758.00

Service Code	HCPCS 76770
Hospital Charge Code	1169867
Hospital Revenue Code	402
Min. Negotiated Rate	$64.94
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$64.94
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$70.56
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$64.94
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$258.91

US Retroperitoneal Complete - Report

Professional

Both

$134.00

Service Code	HCPCS 76770 26
Hospital Charge Code	630894
Hospital Revenue Code	972
Min. Negotiated Rate	$34.70
Max. Negotiated Rate	$127.33
Rate for Payer: AlohaCare Medicaid	$71.79
Rate for Payer: AlohaCare Medicare	$34.70
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$38.17
Rate for Payer: Hawaii Medical Service Association Medicare	$34.70
Rate for Payer: Hawaii Western Management Group Commercial	$127.33
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$41.64
Rate for Payer: Kaiser Permanente Medicaid	$41.64
Rate for Payer: Kaiser Permanente Medicare	$41.64
Rate for Payer: Ohana Health Plan Medicaid	$71.79
Rate for Payer: Ohana Health Plan Medicare	$34.70
Rate for Payer: UnitedHealthcare Medicaid	$71.79
Rate for Payer: UnitedHealthcare Medicare	$34.70

US Retroperitoneal Limited

Facility

$708.00

Service Code	HCPCS 76775
Hospital Charge Code	1169869
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$354.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$202.63

US Retroperitoneal Limited

Facility

$708.00

Service Code	HCPCS 76775
Hospital Charge Code	1169869
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

US Retroperitoneal Limited POC

Facility

$708.00

Service Code	HCPCS 76775
Hospital Charge Code	10248583
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

US Retroperitoneal Limited POC

Facility

$708.00

Service Code	HCPCS 76775
Hospital Charge Code	10248583
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$354.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$202.63

US Retroperitoneal Limited - Report

Professional

Both

$145.00

Service Code	HCPCS 76775 26
Hospital Charge Code	630856
Hospital Revenue Code	972
Min. Negotiated Rate	$27.59
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$38.88
Rate for Payer: AlohaCare Medicare	$27.59
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$30.35
Rate for Payer: Hawaii Medical Service Association Medicare	$27.59
Rate for Payer: Hawaii Western Management Group Commercial	$94.29
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$33.11
Rate for Payer: Kaiser Permanente Medicaid	$33.11
Rate for Payer: Kaiser Permanente Medicare	$33.11
Rate for Payer: Ohana Health Plan Medicaid	$38.88
Rate for Payer: Ohana Health Plan Medicare	$27.59
Rate for Payer: UnitedHealthcare Medicaid	$38.88
Rate for Payer: UnitedHealthcare Medicare	$27.59

US Scrotum Contents

Facility

$758.00

Service Code	HCPCS 76870
Hospital Charge Code	8100937
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

US Scrotum Contents

Facility

$758.00

Service Code	HCPCS 76870
Hospital Charge Code	8100937
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$50.35
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$54.65
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$228.81

US Scrotum (Contents) POC

Facility

$761.00

Service Code	HCPCS 76870
Hospital Charge Code	10239194
Hospital Revenue Code	402
Min. Negotiated Rate	$646.85
Max. Negotiated Rate	$738.17
Rate for Payer: Cash Price	$494.65
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: MDX Hawaii PPO	$738.17

US Scrotum (Contents) POC

Facility

$761.00

Service Code	HCPCS 76870
Hospital Charge Code	10239194
Hospital Revenue Code	402
Min. Negotiated Rate	$50.35
Max. Negotiated Rate	$738.17
Rate for Payer: AlohaCare Medicaid	$380.50
Rate for Payer: AlohaCare Medicare	$380.50
Rate for Payer: Cash Price	$494.65
Rate for Payer: Cash Price	$494.65
Rate for Payer: Devoted Health Medicare	$418.55
Rate for Payer: Hawaii Medical Service Association ABD	$50.35
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$380.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$54.65
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$646.85
Rate for Payer: Humana Medicare	$380.50
Rate for Payer: Kaiser Permanente Commercial	$684.90
Rate for Payer: Kaiser Permanente Medicaid	$388.11
Rate for Payer: Kaiser Permanente Medicare	$380.50
Rate for Payer: MDX Hawaii PPO	$738.17
Rate for Payer: Ohana Health Plan Medicaid	$380.50
Rate for Payer: Ohana Health Plan Medicare	$380.50
Rate for Payer: UnitedHealthcare Medicaid	$50.35
Rate for Payer: UnitedHealthcare Medicare	$380.50
Rate for Payer: University Health Alliance Commercial	$228.81

US Scrotum (Contents) - Report

Professional

Both

$145.00

Service Code	HCPCS 76870 26
Hospital Charge Code	8100939
Hospital Revenue Code	972
Min. Negotiated Rate	$30.22
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$66.47
Rate for Payer: AlohaCare Medicare	$30.22
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$33.24
Rate for Payer: Hawaii Medical Service Association Medicare	$30.22
Rate for Payer: Hawaii Western Management Group Commercial	$101.84
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$36.26
Rate for Payer: Kaiser Permanente Medicaid	$36.26
Rate for Payer: Kaiser Permanente Medicare	$36.26
Rate for Payer: Ohana Health Plan Medicaid	$66.47
Rate for Payer: Ohana Health Plan Medicare	$30.22
Rate for Payer: UnitedHealthcare Medicaid	$66.47
Rate for Payer: UnitedHealthcare Medicare	$30.22

US Segmental Pressures LE 3+ Lvls Bilat

Facility

$698.00

Service Code	HCPCS 93923
Hospital Charge Code	1169755
Hospital Revenue Code	921
Min. Negotiated Rate	$593.30
Max. Negotiated Rate	$677.06
Rate for Payer: Cash Price	$453.70
Rate for Payer: Health Management Network Commercial	$593.30
Rate for Payer: Kaiser Permanente Commercial	$628.20
Rate for Payer: MDX Hawaii PPO	$677.06

US Segmental Pressures LE 3+ Lvls Bilat

Facility

$698.00

Service Code	HCPCS 93923
Hospital Charge Code	1169755
Hospital Revenue Code	921
Min. Negotiated Rate	$102.27
Max. Negotiated Rate	$677.06
Rate for Payer: AlohaCare Medicaid	$349.00
Rate for Payer: AlohaCare Medicare	$349.00
Rate for Payer: Cash Price	$453.70
Rate for Payer: Cash Price	$453.70
Rate for Payer: Devoted Health Medicare	$383.90
Rate for Payer: Hawaii Medical Service Association ABD	$102.27
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$349.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$122.12
Rate for Payer: Hawaii Western Management Group Commercial	$663.10
Rate for Payer: Health Management Network Commercial	$593.30
Rate for Payer: Humana Medicare	$349.00
Rate for Payer: Kaiser Permanente Commercial	$628.20
Rate for Payer: Kaiser Permanente Medicaid	$355.98
Rate for Payer: Kaiser Permanente Medicare	$349.00
Rate for Payer: MDX Hawaii PPO	$677.06
Rate for Payer: Ohana Health Plan Medicaid	$349.00
Rate for Payer: Ohana Health Plan Medicare	$349.00
Rate for Payer: UnitedHealthcare Medicaid	$102.27
Rate for Payer: UnitedHealthcare Medicare	$349.00
Rate for Payer: University Health Alliance Commercial	$390.88

US SMA with Doppler

Facility

$1,895.00

Service Code	HCPCS 93976
Hospital Charge Code	8127582
Hospital Revenue Code	402
Min. Negotiated Rate	$106.34
Max. Negotiated Rate	$1,838.15
Rate for Payer: AlohaCare Medicaid	$947.50
Rate for Payer: AlohaCare Medicare	$947.50
Rate for Payer: Cash Price	$1,231.75
Rate for Payer: Cash Price	$1,231.75
Rate for Payer: Devoted Health Medicare	$1,042.25
Rate for Payer: Hawaii Medical Service Association ABD	$106.34
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$947.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$125.37
Rate for Payer: Hawaii Western Management Group Commercial	$1,800.25
Rate for Payer: Health Management Network Commercial	$1,610.75
Rate for Payer: Humana Medicare	$947.50
Rate for Payer: Kaiser Permanente Commercial	$1,705.50
Rate for Payer: Kaiser Permanente Medicaid	$966.45
Rate for Payer: Kaiser Permanente Medicare	$947.50
Rate for Payer: MDX Hawaii PPO	$1,838.15
Rate for Payer: Ohana Health Plan Medicaid	$947.50
Rate for Payer: Ohana Health Plan Medicare	$947.50
Rate for Payer: UnitedHealthcare Medicaid	$106.34
Rate for Payer: UnitedHealthcare Medicare	$947.50
Rate for Payer: University Health Alliance Commercial	$1,061.20

US SMA with Doppler

Facility

$1,895.00

Service Code	HCPCS 93976
Hospital Charge Code	8127582
Hospital Revenue Code	402
Min. Negotiated Rate	$1,610.75
Max. Negotiated Rate	$1,838.15
Rate for Payer: Cash Price	$1,231.75
Rate for Payer: Health Management Network Commercial	$1,610.75
Rate for Payer: Kaiser Permanente Commercial	$1,705.50
Rate for Payer: MDX Hawaii PPO	$1,838.15

US SMA with Doppler - Report

Professional

Both

$165.00

Service Code	HCPCS 93976 26
Hospital Charge Code	8127584
Hospital Revenue Code	972
Min. Negotiated Rate	$37.65
Max. Negotiated Rate	$176.72
Rate for Payer: AlohaCare Medicaid	$176.72
Rate for Payer: AlohaCare Medicare	$37.65
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Devoted Health Medicare	$41.41
Rate for Payer: Hawaii Medical Service Association Medicare	$37.65
Rate for Payer: Hawaii Western Management Group Commercial	$171.97
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$45.18
Rate for Payer: Kaiser Permanente Medicaid	$45.18
Rate for Payer: Kaiser Permanente Medicare	$45.18
Rate for Payer: Ohana Health Plan Medicaid	$176.72
Rate for Payer: Ohana Health Plan Medicare	$37.65
Rate for Payer: UnitedHealthcare Medicaid	$176.72
Rate for Payer: UnitedHealthcare Medicare	$37.65

US Soft Tissue Abd/Pel

Facility

$708.00

Service Code	HCPCS 76705
Hospital Charge Code	8100943
Hospital Revenue Code	402
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
Rate for Payer: Hawaii Medical Service Association ABD	$46.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$354.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.90
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$46.98
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$200.93

US Soft Tissue Abd/Pel

Facility

$708.00

Service Code	HCPCS 76705
Hospital Charge Code	8100943
Hospital Revenue Code	402
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

US Soft Tissue Abd/Pel - Report

Professional

Both

$144.00

Service Code	HCPCS 76705 26
Hospital Charge Code	8100945
Hospital Revenue Code	972
Min. Negotiated Rate	$27.93
Max. Negotiated Rate	$122.40
Rate for Payer: AlohaCare Medicaid	$57.67
Rate for Payer: AlohaCare Medicare	$27.93
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Devoted Health Medicare	$30.72
Rate for Payer: Hawaii Medical Service Association Medicare	$27.93
Rate for Payer: Hawaii Western Management Group Commercial	$94.64
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$33.52
Rate for Payer: Kaiser Permanente Medicaid	$33.52
Rate for Payer: Kaiser Permanente Medicare	$33.52
Rate for Payer: Ohana Health Plan Medicaid	$57.67
Rate for Payer: Ohana Health Plan Medicare	$27.93
Rate for Payer: UnitedHealthcare Medicaid	$57.67
Rate for Payer: UnitedHealthcare Medicare	$27.93

US Soft Tissue Buttocks or Pelvic Wall

Facility

$1,221.00

Service Code	HCPCS 76857
Hospital Charge Code	8463493
Hospital Revenue Code	402
Min. Negotiated Rate	$44.29
Max. Negotiated Rate	$1,184.37
Rate for Payer: AlohaCare Medicaid	$610.50
Rate for Payer: AlohaCare Medicare	$610.50
Rate for Payer: Cash Price	$793.65
Rate for Payer: Cash Price	$793.65
Rate for Payer: Devoted Health Medicare	$671.55
Rate for Payer: Hawaii Medical Service Association ABD	$44.29
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$610.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$69.53
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$1,037.85
Rate for Payer: Humana Medicare	$610.50
Rate for Payer: Kaiser Permanente Commercial	$1,098.90
Rate for Payer: Kaiser Permanente Medicaid	$622.71
Rate for Payer: Kaiser Permanente Medicare	$610.50
Rate for Payer: MDX Hawaii PPO	$1,184.37
Rate for Payer: Ohana Health Plan Medicaid	$610.50
Rate for Payer: Ohana Health Plan Medicare	$610.50
Rate for Payer: UnitedHealthcare Medicaid	$44.29
Rate for Payer: UnitedHealthcare Medicare	$610.50
Rate for Payer: University Health Alliance Commercial	$161.45

US Soft Tissue Buttocks or Pelvic Wall

Facility

$1,221.00

Service Code	HCPCS 76857
Hospital Charge Code	8463493
Hospital Revenue Code	402
Min. Negotiated Rate	$1,037.85
Max. Negotiated Rate	$1,184.37
Rate for Payer: Cash Price	$793.65
Rate for Payer: Health Management Network Commercial	$1,037.85
Rate for Payer: Kaiser Permanente Commercial	$1,098.90
Rate for Payer: MDX Hawaii PPO	$1,184.37

US Soft Tissue Buttocks or Pelvic Wall - Report

Professional

Both

$145.00

Service Code	HCPCS 76857 26
Hospital Charge Code	8463495
Hospital Revenue Code	972
Min. Negotiated Rate	$24.16
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$32.12
Rate for Payer: AlohaCare Medicare	$24.16
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$26.58
Rate for Payer: Hawaii Medical Service Association Medicare	$24.16
Rate for Payer: Hawaii Western Management Group Commercial	$66.85
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$28.99
Rate for Payer: Kaiser Permanente Medicaid	$28.99
Rate for Payer: Kaiser Permanente Medicare	$28.99
Rate for Payer: Ohana Health Plan Medicaid	$32.12
Rate for Payer: Ohana Health Plan Medicare	$24.16
Rate for Payer: UnitedHealthcare Medicaid	$32.12
Rate for Payer: UnitedHealthcare Medicare	$24.16

US Soft Tissue Chest or Upper Back

Facility

$1,295.00

Service Code	HCPCS 76604
Hospital Charge Code	8463496
Hospital Revenue Code	402
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: Kaiser Permanente Commercial	$1,165.50
Rate for Payer: MDX Hawaii PPO	$1,256.15

Know your out-of-pocket cost for care.

All Charges