|
HC REMV F.B.,EYE,EMBED CONJUNC
|
Facility
|
OP
|
$1,588.00
|
|
|
Service Code
|
HCPCS 65210
|
| Hospital Charge Code |
3616521001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$794.00
|
| Rate for Payer: AlohaCare Medicare |
$1,206.88
|
| Rate for Payer: Cash Price |
$952.80
|
| Rate for Payer: Cash Price |
$952.80
|
| Rate for Payer: Devoted Health Medicare |
$1,333.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,206.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,508.60
|
| Rate for Payer: Health Management Network Commercial |
$1,349.80
|
| Rate for Payer: Humana Medicare |
$1,206.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,429.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,206.88
|
| Rate for Payer: MDX Hawaii PPO |
$1,540.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,206.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,206.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,206.88
|
| Rate for Payer: University Health Alliance Commercial |
$1,157.49
|
|
|
HC REMV F.B.,EYE,SUPERF CONJUNC
|
Facility
|
OP
|
$513.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
4506520501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$256.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$256.50
|
| Rate for Payer: AlohaCare Medicare |
$389.88
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Devoted Health Medicare |
$430.92
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$389.88
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$487.35
|
| Rate for Payer: Health Management Network Commercial |
$436.05
|
| Rate for Payer: Humana Medicare |
$389.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$461.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$389.88
|
| Rate for Payer: MDX Hawaii PPO |
$497.61
|
| Rate for Payer: Ohana Health Plan Medicaid |
$389.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$389.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$389.88
|
| Rate for Payer: University Health Alliance Commercial |
$373.93
|
|
|
HC REMV F.B.,EYE,SUPERF CONJUNC
|
Facility
|
IP
|
$513.00
|
|
|
Service Code
|
HCPCS 65205
|
| Hospital Charge Code |
4506520501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$436.05 |
| Max. Negotiated Rate |
$497.61 |
| Rate for Payer: Cash Price |
$307.80
|
| Rate for Payer: Health Management Network Commercial |
$436.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$461.70
|
| Rate for Payer: MDX Hawaii PPO |
$497.61
|
|
|
HC RENAL FUNCTION PANEL - BUNDLED CHARGE
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 80069
|
| Hospital Charge Code |
3018006901
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.05 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
|
|
HC RENAL FUNCTION PANEL - BUNDLED CHARGE
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 80069
|
| Hospital Charge Code |
3018006901
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$70.81 |
| Rate for Payer: AlohaCare Medicaid |
$36.50
|
| Rate for Payer: AlohaCare Medicare |
$55.48
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Devoted Health Medicare |
$61.32
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$12.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$10.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$55.48
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$12.60
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$8.68
|
| Rate for Payer: Health Management Network Commercial |
$62.05
|
| Rate for Payer: Humana Medicare |
$55.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$37.23
|
| Rate for Payer: Kaiser Permanente Medicare |
$55.48
|
| Rate for Payer: MDX Hawaii PPO |
$70.81
|
| Rate for Payer: Ohana Health Plan Medicaid |
$55.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$55.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$55.48
|
| Rate for Payer: University Health Alliance Commercial |
$22.44
|
|
|
HC REPAIR, COMPLEX, EYELIDS, NOSE, EARS, LIPS; EACH ADDITIONAL 5 CM OR LESS
|
Facility
|
IP
|
$785.00
|
|
|
Service Code
|
HCPCS 13153
|
| Hospital Charge Code |
4501315301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$667.25 |
| Max. Negotiated Rate |
$761.45 |
| Rate for Payer: Cash Price |
$471.00
|
| Rate for Payer: Health Management Network Commercial |
$667.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$706.50
|
| Rate for Payer: MDX Hawaii PPO |
$761.45
|
|
|
HC REPAIR, COMPLEX, EYELIDS, NOSE, EARS, LIPS; EACH ADDITIONAL 5 CM OR LESS
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 13153
|
| Hospital Charge Code |
4501315301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$392.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$392.50
|
| Rate for Payer: AlohaCare Medicare |
$596.60
|
| Rate for Payer: Cash Price |
$471.00
|
| Rate for Payer: Cash Price |
$471.00
|
| Rate for Payer: Devoted Health Medicare |
$659.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$596.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$745.75
|
| Rate for Payer: Health Management Network Commercial |
$667.25
|
| Rate for Payer: Humana Medicare |
$596.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$706.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$596.60
|
| Rate for Payer: MDX Hawaii PPO |
$761.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$596.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$596.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$596.60
|
| Rate for Payer: University Health Alliance Commercial |
$572.19
|
|
|
HC REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM
|
Facility
|
IP
|
$2,436.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
4501312001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,070.60 |
| Max. Negotiated Rate |
$2,362.92 |
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Health Management Network Commercial |
$2,070.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,192.40
|
| Rate for Payer: MDX Hawaii PPO |
$2,362.92
|
|
|
HC REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM
|
Facility
|
OP
|
$2,436.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
4501312001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$2,362.92 |
| Rate for Payer: AlohaCare Medicaid |
$1,218.00
|
| Rate for Payer: AlohaCare Medicare |
$1,851.36
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Cash Price |
$1,461.60
|
| Rate for Payer: Devoted Health Medicare |
$2,046.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,851.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,314.20
|
| Rate for Payer: Health Management Network Commercial |
$2,070.60
|
| Rate for Payer: Humana Medicare |
$1,851.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,192.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,851.36
|
| Rate for Payer: MDX Hawaii PPO |
$2,362.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,851.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,851.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,851.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,775.60
|
|
|
HC REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM
|
Facility
|
OP
|
$2,385.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
4501310001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$2,313.45 |
| Rate for Payer: AlohaCare Medicaid |
$1,192.50
|
| Rate for Payer: AlohaCare Medicare |
$1,812.60
|
| Rate for Payer: Cash Price |
$1,431.00
|
| Rate for Payer: Cash Price |
$1,431.00
|
| Rate for Payer: Devoted Health Medicare |
$2,003.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,812.60
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,265.75
|
| Rate for Payer: Health Management Network Commercial |
$2,027.25
|
| Rate for Payer: Humana Medicare |
$1,812.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,146.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,812.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,313.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,812.60
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,812.60
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,812.60
|
| Rate for Payer: University Health Alliance Commercial |
$1,738.43
|
|
|
HC REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM
|
Facility
|
IP
|
$2,385.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
4501310001
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,027.25 |
| Max. Negotiated Rate |
$2,313.45 |
| Rate for Payer: Cash Price |
$1,431.00
|
| Rate for Payer: Health Management Network Commercial |
$2,027.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,146.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,313.45
|
|
|
HC REPAIR LIP,<1/2 VERT HEIGHT
|
Facility
|
IP
|
$2,027.00
|
|
|
Service Code
|
HCPCS 40652
|
| Hospital Charge Code |
7614065201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,722.95 |
| Max. Negotiated Rate |
$1,966.19 |
| Rate for Payer: Cash Price |
$1,216.20
|
| Rate for Payer: Health Management Network Commercial |
$1,722.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,824.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,966.19
|
|
|
HC REPAIR LIP,<1/2 VERT HEIGHT
|
Facility
|
OP
|
$2,027.00
|
|
|
Service Code
|
HCPCS 40652
|
| Hospital Charge Code |
7614065201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,966.19 |
| Rate for Payer: AlohaCare Medicaid |
$1,013.50
|
| Rate for Payer: AlohaCare Medicare |
$1,540.52
|
| Rate for Payer: Cash Price |
$1,216.20
|
| Rate for Payer: Cash Price |
$1,216.20
|
| Rate for Payer: Devoted Health Medicare |
$1,702.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,540.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,925.65
|
| Rate for Payer: Health Management Network Commercial |
$1,722.95
|
| Rate for Payer: Humana Medicare |
$1,540.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,824.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,540.52
|
| Rate for Payer: MDX Hawaii PPO |
$1,966.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,540.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,540.52
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,540.52
|
| Rate for Payer: University Health Alliance Commercial |
$1,477.48
|
|
|
HC REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT
|
Facility
|
IP
|
$5,772.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
4504065401
|
|
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: Kaiser Permanente Commercial |
$5,194.80
|
| Rate for Payer: MDX Hawaii PPO |
$5,598.84
|
|
|
HC REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT
|
Facility
|
OP
|
$5,772.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
4504065401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$5,598.84 |
| Rate for Payer: AlohaCare Medicaid |
$2,886.00
|
| Rate for Payer: AlohaCare Medicare |
$4,386.72
|
| Rate for Payer: Cash Price |
$3,463.20
|
| Rate for Payer: Cash Price |
$3,463.20
|
| Rate for Payer: Devoted Health Medicare |
$4,848.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,386.72
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,483.40
|
| Rate for Payer: Health Management Network Commercial |
$4,906.20
|
| Rate for Payer: Humana Medicare |
$4,386.72
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,194.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,386.72
|
| Rate for Payer: MDX Hawaii PPO |
$5,598.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,386.72
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,386.72
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,386.72
|
| Rate for Payer: University Health Alliance Commercial |
$4,207.21
|
|
|
HC REPAIR OF PALATE, OVER 2 CM OR REQUIRING COMPLEX REPAIR
|
Facility
|
IP
|
$23,052.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
4504218201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$19,594.20 |
| Max. Negotiated Rate |
$22,360.44 |
| Rate for Payer: Cash Price |
$13,831.20
|
| Rate for Payer: Health Management Network Commercial |
$19,594.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,746.80
|
| Rate for Payer: MDX Hawaii PPO |
$22,360.44
|
|
|
HC REPAIR OF PALATE, OVER 2 CM OR REQUIRING COMPLEX REPAIR
|
Facility
|
OP
|
$23,052.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
4504218201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$22,360.44 |
| Rate for Payer: AlohaCare Medicaid |
$11,526.00
|
| Rate for Payer: AlohaCare Medicare |
$17,519.52
|
| Rate for Payer: Cash Price |
$13,831.20
|
| Rate for Payer: Cash Price |
$13,831.20
|
| Rate for Payer: Devoted Health Medicare |
$19,363.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$17,519.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21,899.40
|
| Rate for Payer: Health Management Network Commercial |
$19,594.20
|
| Rate for Payer: Humana Medicare |
$17,519.52
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,746.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$17,519.52
|
| Rate for Payer: MDX Hawaii PPO |
$22,360.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$17,519.52
|
| Rate for Payer: Ohana Health Plan Medicare |
$17,519.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$17,519.52
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
HC REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE
|
Facility
|
OP
|
$27,837.00
|
|
|
Service Code
|
HCPCS 24341
|
| Hospital Charge Code |
4502434101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$27,001.89 |
| Rate for Payer: AlohaCare Medicaid |
$13,918.50
|
| Rate for Payer: AlohaCare Medicare |
$21,156.12
|
| Rate for Payer: Cash Price |
$16,702.20
|
| Rate for Payer: Cash Price |
$16,702.20
|
| Rate for Payer: Devoted Health Medicare |
$23,383.08
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21,156.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26,445.15
|
| Rate for Payer: Health Management Network Commercial |
$23,661.45
|
| Rate for Payer: Humana Medicare |
$21,156.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$25,053.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$21,156.12
|
| Rate for Payer: MDX Hawaii PPO |
$27,001.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$21,156.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$21,156.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$21,156.12
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
HC REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE
|
Facility
|
IP
|
$27,837.00
|
|
|
Service Code
|
HCPCS 24341
|
| Hospital Charge Code |
4502434101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$23,661.45 |
| Max. Negotiated Rate |
$27,001.89 |
| Rate for Payer: Cash Price |
$16,702.20
|
| Rate for Payer: Health Management Network Commercial |
$23,661.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$25,053.30
|
| Rate for Payer: MDX Hawaii PPO |
$27,001.89
|
|
|
HC REPAIR TONGUE LACER,POST 1/3
|
Facility
|
OP
|
$924.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
7614125101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$462.00
|
| Rate for Payer: AlohaCare Medicare |
$702.24
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Devoted Health Medicare |
$776.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$702.24
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$877.80
|
| Rate for Payer: Health Management Network Commercial |
$785.40
|
| Rate for Payer: Humana Medicare |
$702.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$831.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$702.24
|
| Rate for Payer: MDX Hawaii PPO |
$896.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$702.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$702.24
|
| Rate for Payer: UnitedHealthcare Medicare |
$702.24
|
| Rate for Payer: University Health Alliance Commercial |
$673.50
|
|
|
HC REPAIR TONGUE LACER,POST 1/3
|
Facility
|
IP
|
$924.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
7614125101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$785.40 |
| Max. Negotiated Rate |
$896.28 |
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Health Management Network Commercial |
$785.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$831.60
|
| Rate for Payer: MDX Hawaii PPO |
$896.28
|
|
|
HC REPOSITION GASTROSTOMY TUBE - GASTROSTOMY TUBE, CHANGE / REPOSITION
|
Facility
|
IP
|
$968.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
7504376101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$822.80 |
| Max. Negotiated Rate |
$938.96 |
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Health Management Network Commercial |
$822.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$871.20
|
| Rate for Payer: MDX Hawaii PPO |
$938.96
|
|
|
HC REPOSITION GASTROSTOMY TUBE - GASTROSTOMY TUBE, CHANGE / REPOSITION
|
Facility
|
OP
|
$968.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
7504376101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$484.00
|
| Rate for Payer: AlohaCare Medicare |
$735.68
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Devoted Health Medicare |
$813.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$735.68
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$919.60
|
| Rate for Payer: Health Management Network Commercial |
$822.80
|
| Rate for Payer: Humana Medicare |
$735.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$871.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$735.68
|
| Rate for Payer: MDX Hawaii PPO |
$938.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$735.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$735.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$735.68
|
| Rate for Payer: University Health Alliance Commercial |
$705.58
|
|
|
HC REP,SKIN,TRUNK,CMPLX,+5 CM/<
|
Facility
|
OP
|
$1,811.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
7611310201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,756.67 |
| Rate for Payer: AlohaCare Medicaid |
$905.50
|
| Rate for Payer: AlohaCare Medicare |
$1,376.36
|
| Rate for Payer: Cash Price |
$1,086.60
|
| Rate for Payer: Cash Price |
$1,086.60
|
| Rate for Payer: Devoted Health Medicare |
$1,521.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,376.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,720.45
|
| Rate for Payer: Health Management Network Commercial |
$1,539.35
|
| Rate for Payer: Humana Medicare |
$1,376.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,629.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,376.36
|
| Rate for Payer: MDX Hawaii PPO |
$1,756.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,376.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,376.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,376.36
|
| Rate for Payer: University Health Alliance Commercial |
$1,320.04
|
|
|
HC REP,SKIN,TRUNK,CMPLX,+5 CM/<
|
Facility
|
IP
|
$1,811.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
7611310201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,539.35 |
| Max. Negotiated Rate |
$1,756.67 |
| Rate for Payer: Cash Price |
$1,086.60
|
| Rate for Payer: Health Management Network Commercial |
$1,539.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,629.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,756.67
|
|
