|
HC CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 24650
|
| Hospital Charge Code |
4502465001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$589.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 24650
|
| Hospital Charge Code |
4502465001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC CLOSED TREATMENT OF RADIOULNAR JOINT DISLOCATION; WITH MANIPULATION
|
Facility
|
IP
|
$955.00
|
|
|
Service Code
|
HCPCS 25675
|
| Hospital Charge Code |
4502567501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$811.75 |
| Max. Negotiated Rate |
$926.35 |
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Health Management Network Commercial |
$811.75
|
| Rate for Payer: MDX Hawaii PPO |
$926.35
|
|
|
HC CLOSED TREATMENT OF RADIOULNAR JOINT DISLOCATION; WITH MANIPULATION
|
Facility
|
OP
|
$955.00
|
|
|
Service Code
|
HCPCS 25675
|
| Hospital Charge Code |
4502567501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$2,536.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Cash Price |
$573.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$907.25
|
| Rate for Payer: Health Management Network Commercial |
$811.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$601.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$926.35
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$696.10
|
|
|
HC CLOSED TREATMENT OF SCAPULAR FRACTURE; WITHOUT MANIPULATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 23570
|
| Hospital Charge Code |
4502357001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$2,536.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$589.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC CLOSED TREATMENT OF SCAPULAR FRACTURE; WITHOUT MANIPULATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 23570
|
| Hospital Charge Code |
4502357001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITH MANIPULATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 23525
|
| Hospital Charge Code |
4502352501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$589.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITH MANIPULATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 23525
|
| Hospital Charge Code |
4502352501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITHOUT MANIPULATION
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS 23520
|
| Hospital Charge Code |
4502352001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$6,048.92 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,924.20
|
| Rate for Payer: Health Management Network Commercial |
$5,300.60
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,928.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: MDX Hawaii PPO |
$6,048.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
| Rate for Payer: University Health Alliance Commercial |
$4,545.42
|
|
|
HC CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITHOUT MANIPULATION
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS 23520
|
| Hospital Charge Code |
4502352001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,300.60 |
| Max. Negotiated Rate |
$6,048.92 |
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Health Management Network Commercial |
$5,300.60
|
| Rate for Payer: MDX Hawaii PPO |
$6,048.92
|
|
|
HC CLOSED TREATMENT OF STERNUM FRACTURE; WITHOUT MANIPULATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 21820
|
| Hospital Charge Code |
4502182001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC CLOSED TREATMENT OF STERNUM FRACTURE; WITHOUT MANIPULATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 21820
|
| Hospital Charge Code |
4502182001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$589.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC CLOSED TREATMENT OF SUPRACONDYLAR FEMORAL FRACTURE, WITH MANIPULATION
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS 27503
|
| Hospital Charge Code |
4502750301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,300.60 |
| Max. Negotiated Rate |
$6,048.92 |
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Health Management Network Commercial |
$5,300.60
|
| Rate for Payer: MDX Hawaii PPO |
$6,048.92
|
|
|
HC CLOSED TREATMENT OF SUPRACONDYLAR FEMORAL FRACTURE, WITH MANIPULATION
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS 27503
|
| Hospital Charge Code |
4502750301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$6,048.92 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,924.20
|
| Rate for Payer: Health Management Network Commercial |
$5,300.60
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,928.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: MDX Hawaii PPO |
$6,048.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
| Rate for Payer: University Health Alliance Commercial |
$4,545.42
|
|
|
HC CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; WITH ANESTHESIA
|
Facility
|
OP
|
$12,643.00
|
|
|
Service Code
|
HCPCS 28575
|
| Hospital Charge Code |
4502857501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$393.00 |
| Max. Negotiated Rate |
$12,263.71 |
| Rate for Payer: AlohaCare Medicaid |
$3,865.36
|
| Rate for Payer: AlohaCare Medicare |
$3,865.36
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Devoted Health Medicare |
$4,251.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$393.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$2,536.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,865.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$496.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,010.85
|
| Rate for Payer: Health Management Network Commercial |
$10,746.55
|
| Rate for Payer: Humana Medicare |
$3,865.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,965.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,865.36
|
| Rate for Payer: MDX Hawaii PPO |
$12,263.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,251.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,865.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,865.36
|
| Rate for Payer: University Health Alliance Commercial |
$9,215.48
|
|
|
HC CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; WITH ANESTHESIA
|
Facility
|
IP
|
$12,643.00
|
|
|
Service Code
|
HCPCS 28575
|
| Hospital Charge Code |
4502857501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$10,746.55 |
| Max. Negotiated Rate |
$12,263.71 |
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Health Management Network Commercial |
$10,746.55
|
| Rate for Payer: MDX Hawaii PPO |
$12,263.71
|
|
|
HC CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; WITHOUT ANESTHESIA
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 28570
|
| Hospital Charge Code |
4502857001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; WITHOUT ANESTHESIA
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 28570
|
| Hospital Charge Code |
4502857001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$589.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; WITH ANESTHESIA
|
Facility
|
IP
|
$12,643.00
|
|
|
Service Code
|
HCPCS 28545
|
| Hospital Charge Code |
4502854501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$10,746.55 |
| Max. Negotiated Rate |
$12,263.71 |
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Health Management Network Commercial |
$10,746.55
|
| Rate for Payer: MDX Hawaii PPO |
$12,263.71
|
|
|
HC CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; WITH ANESTHESIA
|
Facility
|
OP
|
$12,643.00
|
|
|
Service Code
|
HCPCS 28545
|
| Hospital Charge Code |
4502854501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$12,263.71 |
| Rate for Payer: AlohaCare Medicaid |
$3,865.36
|
| Rate for Payer: AlohaCare Medicare |
$3,865.36
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Cash Price |
$7,585.80
|
| Rate for Payer: Devoted Health Medicare |
$4,251.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$3,865.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,010.85
|
| Rate for Payer: Health Management Network Commercial |
$10,746.55
|
| Rate for Payer: Humana Medicare |
$3,865.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,965.09
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$3,865.36
|
| Rate for Payer: MDX Hawaii PPO |
$12,263.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,251.90
|
| Rate for Payer: Ohana Health Plan Medicare |
$3,865.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$3,865.36
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
HC CLOSED TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS); WITHOUT MANIPULATION
|
Facility
|
OP
|
$935.00
|
|
|
Service Code
|
HCPCS 28430
|
| Hospital Charge Code |
4502843001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$291.40 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$291.40
|
| Rate for Payer: AlohaCare Medicare |
$291.40
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Devoted Health Medicare |
$320.54
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$291.40
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$888.25
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: Humana Medicare |
$291.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$589.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$291.40
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$320.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$291.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$291.40
|
| Rate for Payer: University Health Alliance Commercial |
$681.52
|
|
|
HC CLOSED TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS); WITHOUT MANIPULATION
|
Facility
|
IP
|
$935.00
|
|
|
Service Code
|
HCPCS 28430
|
| Hospital Charge Code |
4502843001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$794.75 |
| Max. Negotiated Rate |
$906.95 |
| Rate for Payer: Cash Price |
$561.00
|
| Rate for Payer: Health Management Network Commercial |
$794.75
|
| Rate for Payer: MDX Hawaii PPO |
$906.95
|
|
|
HC CLOSED TREATMENT OF TARSAL BONE FX (EXCEPT TALUS AND CALCANEUS); WITH MANIPULATION
|
Facility
|
OP
|
$6,236.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
4502845501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$6,048.92 |
| Rate for Payer: AlohaCare Medicaid |
$1,899.59
|
| Rate for Payer: AlohaCare Medicare |
$1,899.59
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Devoted Health Medicare |
$2,089.55
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$569.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,899.59
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,924.20
|
| Rate for Payer: Health Management Network Commercial |
$5,300.60
|
| Rate for Payer: Humana Medicare |
$1,899.59
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,928.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,899.59
|
| Rate for Payer: MDX Hawaii PPO |
$6,048.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,089.55
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,899.59
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,899.59
|
| Rate for Payer: University Health Alliance Commercial |
$4,545.42
|
|
|
HC CLOSED TREATMENT OF TARSAL BONE FX (EXCEPT TALUS AND CALCANEUS); WITH MANIPULATION
|
Facility
|
IP
|
$6,236.00
|
|
|
Service Code
|
HCPCS 28455
|
| Hospital Charge Code |
4502845501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,300.60 |
| Max. Negotiated Rate |
$6,048.92 |
| Rate for Payer: Cash Price |
$3,741.60
|
| Rate for Payer: Health Management Network Commercial |
$5,300.60
|
| Rate for Payer: MDX Hawaii PPO |
$6,048.92
|
|
|
HC CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (E.G., RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT
|
Facility
|
IP
|
$5,772.00
|
|
|
Service Code
|
HCPCS 21485
|
| Hospital Charge Code |
4502148501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4,906.20 |
| Max. Negotiated Rate |
$5,598.84 |
| Rate for Payer: Cash Price |
$3,463.20
|
| Rate for Payer: Health Management Network Commercial |
$4,906.20
|
| Rate for Payer: MDX Hawaii PPO |
$5,598.84
|
|
