|
440213380 OPN TRT NASOETHMD FX WO EXT FXN ED Charg
|
Facility
|
IP
|
$18,199.00
|
|
|
Service Code
|
HCPCS 21338
|
| Hospital Charge Code |
440213380
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$15,469.15 |
| Max. Negotiated Rate |
$17,653.03 |
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Health Management Network Commercial |
$15,469.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,379.10
|
| Rate for Payer: MDX Hawaii PPO |
$17,653.03
|
|
|
440213380 OPN TRT NASOETHMD FX WO EXT FXN ED Charg
|
Facility
|
OP
|
$18,199.00
|
|
|
Service Code
|
HCPCS 21338
|
| Hospital Charge Code |
440213380
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$17,653.03 |
| Rate for Payer: AlohaCare Medicaid |
$9,099.50
|
| Rate for Payer: AlohaCare Medicare |
$7,643.58
|
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$16,743.08
|
| Rate for Payer: Devoted Health Medicare |
$7,643.58
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,643.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17,289.05
|
| Rate for Payer: Health Management Network Commercial |
$15,469.15
|
| Rate for Payer: Humana Medicare |
$7,643.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,379.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,643.58
|
| Rate for Payer: MDX Hawaii PPO |
$17,653.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,643.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,643.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,643.58
|
| Rate for Payer: University Health Alliance Commercial |
$10,679.55
|
|
|
440214510 CLS TRT MANDIBULAR FX W MANIP ED Charge
|
Facility
|
IP
|
$6,219.00
|
|
|
Service Code
|
HCPCS 21451
|
| Hospital Charge Code |
440214510
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,286.15 |
| Max. Negotiated Rate |
$6,032.43 |
| Rate for Payer: Cash Price |
$4,042.35
|
| Rate for Payer: Health Management Network Commercial |
$5,286.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,597.10
|
| Rate for Payer: MDX Hawaii PPO |
$6,032.43
|
|
|
440214510 CLS TRT MANDIBULAR FX W MANIP ED Charge
|
Facility
|
OP
|
$6,219.00
|
|
|
Service Code
|
HCPCS 21451
|
| Hospital Charge Code |
440214510
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$6,032.43 |
| Rate for Payer: AlohaCare Medicaid |
$3,109.50
|
| Rate for Payer: AlohaCare Medicare |
$2,611.98
|
| Rate for Payer: Cash Price |
$4,042.35
|
| Rate for Payer: Cash Price |
$4,042.35
|
| Rate for Payer: Cash Price |
$4,042.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$5,721.48
|
| Rate for Payer: Devoted Health Medicare |
$2,611.98
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,611.98
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,908.05
|
| Rate for Payer: Health Management Network Commercial |
$5,286.15
|
| Rate for Payer: Humana Medicare |
$2,611.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,597.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,611.98
|
| Rate for Payer: MDX Hawaii PPO |
$6,032.43
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,611.98
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,611.98
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,611.98
|
| Rate for Payer: University Health Alliance Commercial |
$4,533.03
|
|
|
440214900 OPN TRT TEMPOROMNDIBLR DISLOC ED Charge
|
Facility
|
OP
|
$18,199.00
|
|
|
Service Code
|
HCPCS 21490
|
| Hospital Charge Code |
440214900
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$17,653.03 |
| Rate for Payer: AlohaCare Medicaid |
$9,099.50
|
| Rate for Payer: AlohaCare Medicare |
$7,643.58
|
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$16,743.08
|
| Rate for Payer: Devoted Health Medicare |
$7,643.58
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,643.58
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$17,289.05
|
| Rate for Payer: Health Management Network Commercial |
$15,469.15
|
| Rate for Payer: Humana Medicare |
$7,643.58
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,379.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,643.58
|
| Rate for Payer: MDX Hawaii PPO |
$17,653.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,643.58
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,643.58
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,643.58
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440214900 OPN TRT TEMPOROMNDIBLR DISLOC ED Charge
|
Facility
|
IP
|
$18,199.00
|
|
|
Service Code
|
HCPCS 21490
|
| Hospital Charge Code |
440214900
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$15,469.15 |
| Max. Negotiated Rate |
$17,653.03 |
| Rate for Payer: Cash Price |
$11,829.35
|
| Rate for Payer: Health Management Network Commercial |
$15,469.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$16,379.10
|
| Rate for Payer: MDX Hawaii PPO |
$17,653.03
|
|
|
440223100 CLS TRT VERT BODY FRAC ED Charge
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 22310
|
| Hospital Charge Code |
440223100
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$753.95 |
| Max. Negotiated Rate |
$860.39 |
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
|
|
440223100 CLS TRT VERT BODY FRAC ED Charge
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 22310
|
| Hospital Charge Code |
440223100
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$372.54 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$443.50
|
| Rate for Payer: AlohaCare Medicare |
$372.54
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Cash Price |
$576.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$816.04
|
| Rate for Payer: Devoted Health Medicare |
$372.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$372.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$842.65
|
| Rate for Payer: Health Management Network Commercial |
$753.95
|
| Rate for Payer: Humana Medicare |
$372.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$798.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$372.54
|
| Rate for Payer: MDX Hawaii PPO |
$860.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$372.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$372.54
|
| Rate for Payer: UnitedHealthcare Medicare |
$372.54
|
| Rate for Payer: University Health Alliance Commercial |
$646.53
|
|
|
440234050 TENOTOMY SHLDR AREA SNGL TENDON ED Charg
|
Facility
|
IP
|
$13,151.00
|
|
|
Service Code
|
HCPCS 23405
|
| Hospital Charge Code |
440234050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$11,178.35 |
| Max. Negotiated Rate |
$12,756.47 |
| Rate for Payer: Cash Price |
$8,548.15
|
| Rate for Payer: Health Management Network Commercial |
$11,178.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,835.90
|
| Rate for Payer: MDX Hawaii PPO |
$12,756.47
|
|
|
440234050 TENOTOMY SHLDR AREA SNGL TENDON ED Charg
|
Facility
|
OP
|
$13,151.00
|
|
|
Service Code
|
HCPCS 23405
|
| Hospital Charge Code |
440234050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$12,756.47 |
| Rate for Payer: AlohaCare Medicaid |
$6,575.50
|
| Rate for Payer: AlohaCare Medicare |
$5,523.42
|
| Rate for Payer: Cash Price |
$8,548.15
|
| Rate for Payer: Cash Price |
$8,548.15
|
| Rate for Payer: Cash Price |
$8,548.15
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$12,098.92
|
| Rate for Payer: Devoted Health Medicare |
$5,523.42
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$5,523.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$12,493.45
|
| Rate for Payer: Health Management Network Commercial |
$11,178.35
|
| Rate for Payer: Humana Medicare |
$5,523.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$11,835.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$5,523.42
|
| Rate for Payer: MDX Hawaii PPO |
$12,756.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$5,523.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$5,523.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$5,523.42
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
440235300 OPN TRT STERNOCLVCLR DISLOC ED Charge
|
Facility
|
OP
|
$21,060.00
|
|
|
Service Code
|
HCPCS 23530
|
| Hospital Charge Code |
440235300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$20,428.20 |
| Rate for Payer: AlohaCare Medicaid |
$10,530.00
|
| Rate for Payer: AlohaCare Medicare |
$8,845.20
|
| Rate for Payer: Cash Price |
$13,689.00
|
| Rate for Payer: Cash Price |
$13,689.00
|
| Rate for Payer: Cash Price |
$13,689.00
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$19,375.20
|
| Rate for Payer: Devoted Health Medicare |
$8,845.20
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,845.20
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$20,007.00
|
| Rate for Payer: Health Management Network Commercial |
$17,901.00
|
| Rate for Payer: Humana Medicare |
$8,845.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$18,954.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,845.20
|
| Rate for Payer: MDX Hawaii PPO |
$20,428.20
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,845.20
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,845.20
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,845.20
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440235300 OPN TRT STERNOCLVCLR DISLOC ED Charge
|
Facility
|
IP
|
$21,060.00
|
|
|
Service Code
|
HCPCS 23530
|
| Hospital Charge Code |
440235300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$17,901.00 |
| Max. Negotiated Rate |
$20,428.20 |
| Rate for Payer: Cash Price |
$13,689.00
|
| Rate for Payer: Health Management Network Commercial |
$17,901.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$18,954.00
|
| Rate for Payer: MDX Hawaii PPO |
$20,428.20
|
|
|
440236250 CLS TRT GR HUM FX W/MAN ED Charge
|
Facility
|
IP
|
$6,394.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
440236250
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,434.90 |
| Max. Negotiated Rate |
$6,202.18 |
| Rate for Payer: Cash Price |
$4,156.10
|
| Rate for Payer: Health Management Network Commercial |
$5,434.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,754.60
|
| Rate for Payer: MDX Hawaii PPO |
$6,202.18
|
|
|
440236250 CLS TRT GR HUM FX W/MAN ED Charge
|
Facility
|
OP
|
$6,394.00
|
|
|
Service Code
|
HCPCS 23625
|
| Hospital Charge Code |
440236250
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$6,202.18 |
| Rate for Payer: AlohaCare Medicaid |
$3,197.00
|
| Rate for Payer: AlohaCare Medicare |
$2,685.48
|
| Rate for Payer: Cash Price |
$4,156.10
|
| Rate for Payer: Cash Price |
$4,156.10
|
| Rate for Payer: Cash Price |
$4,156.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$5,882.48
|
| Rate for Payer: Devoted Health Medicare |
$2,685.48
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,685.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,074.30
|
| Rate for Payer: Health Management Network Commercial |
$5,434.90
|
| Rate for Payer: Humana Medicare |
$2,685.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,754.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,685.48
|
| Rate for Payer: MDX Hawaii PPO |
$6,202.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,685.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,685.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,685.48
|
| Rate for Payer: University Health Alliance Commercial |
$4,660.59
|
|
|
440239310 I&D UPPR ARM ELBOW BURSA ED Charge
|
Facility
|
IP
|
$4,314.00
|
|
|
Service Code
|
HCPCS 23931
|
| Hospital Charge Code |
440239310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3,666.90 |
| Max. Negotiated Rate |
$4,184.58 |
| Rate for Payer: Cash Price |
$2,804.10
|
| Rate for Payer: Health Management Network Commercial |
$3,666.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,882.60
|
| Rate for Payer: MDX Hawaii PPO |
$4,184.58
|
|
|
440239310 I&D UPPR ARM ELBOW BURSA ED Charge
|
Facility
|
OP
|
$4,314.00
|
|
|
Service Code
|
HCPCS 23931
|
| Hospital Charge Code |
440239310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$5,160.40 |
| Rate for Payer: AlohaCare Medicaid |
$2,157.00
|
| Rate for Payer: AlohaCare Medicare |
$1,811.88
|
| Rate for Payer: Cash Price |
$2,804.10
|
| Rate for Payer: Cash Price |
$2,804.10
|
| Rate for Payer: Cash Price |
$2,804.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$3,968.88
|
| Rate for Payer: Devoted Health Medicare |
$1,811.88
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,811.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$4,098.30
|
| Rate for Payer: Health Management Network Commercial |
$3,666.90
|
| Rate for Payer: Humana Medicare |
$1,811.88
|
| Rate for Payer: Kaiser Permanente Commercial |
$3,882.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,811.88
|
| Rate for Payer: MDX Hawaii PPO |
$4,184.58
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,811.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,811.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,811.88
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
440246150 OPN TRT ACUT CHRNC ELBW DISCLC ED Charge
|
Facility
|
OP
|
$27,486.00
|
|
|
Service Code
|
HCPCS 24615
|
| Hospital Charge Code |
440246150
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$26,661.42 |
| Rate for Payer: AlohaCare Medicaid |
$13,743.00
|
| Rate for Payer: AlohaCare Medicare |
$11,544.12
|
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$25,287.12
|
| Rate for Payer: Devoted Health Medicare |
$11,544.12
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,544.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26,111.70
|
| Rate for Payer: Health Management Network Commercial |
$23,363.10
|
| Rate for Payer: Humana Medicare |
$11,544.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$24,737.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,544.12
|
| Rate for Payer: MDX Hawaii PPO |
$26,661.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,544.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,544.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,544.12
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440246150 OPN TRT ACUT CHRNC ELBW DISCLC ED Charge
|
Facility
|
IP
|
$27,486.00
|
|
|
Service Code
|
HCPCS 24615
|
| Hospital Charge Code |
440246150
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$23,363.10 |
| Max. Negotiated Rate |
$26,661.42 |
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Health Management Network Commercial |
$23,363.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$24,737.40
|
| Rate for Payer: MDX Hawaii PPO |
$26,661.42
|
|
|
440246350 OPN TRT MONTEGGIA FX DISLOC ELBOW ED Cha
|
Facility
|
OP
|
$27,486.00
|
|
|
Service Code
|
HCPCS 24635
|
| Hospital Charge Code |
440246350
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$26,661.42 |
| Rate for Payer: AlohaCare Medicaid |
$13,743.00
|
| Rate for Payer: AlohaCare Medicare |
$11,544.12
|
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$25,287.12
|
| Rate for Payer: Devoted Health Medicare |
$11,544.12
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$11,544.12
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26,111.70
|
| Rate for Payer: Health Management Network Commercial |
$23,363.10
|
| Rate for Payer: Humana Medicare |
$11,544.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$24,737.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$11,544.12
|
| Rate for Payer: MDX Hawaii PPO |
$26,661.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$11,544.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$11,544.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$11,544.12
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440246350 OPN TRT MONTEGGIA FX DISLOC ELBOW ED Cha
|
Facility
|
IP
|
$27,486.00
|
|
|
Service Code
|
HCPCS 24635
|
| Hospital Charge Code |
440246350
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$23,363.10 |
| Max. Negotiated Rate |
$26,661.42 |
| Rate for Payer: Cash Price |
$17,865.90
|
| Rate for Payer: Health Management Network Commercial |
$23,363.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$24,737.40
|
| Rate for Payer: MDX Hawaii PPO |
$26,661.42
|
|
|
440256240 CLS TRT NAVICULAR FX W MANIP ED Charges
|
Facility
|
OP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 25624
|
| Hospital Charge Code |
440256240
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$2,225.18 |
| Rate for Payer: AlohaCare Medicaid |
$1,147.00
|
| Rate for Payer: AlohaCare Medicare |
$963.48
|
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$2,110.48
|
| Rate for Payer: Devoted Health Medicare |
$963.48
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$963.48
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,179.30
|
| Rate for Payer: Health Management Network Commercial |
$1,949.90
|
| Rate for Payer: Humana Medicare |
$963.48
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,064.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$963.48
|
| Rate for Payer: MDX Hawaii PPO |
$2,225.18
|
| Rate for Payer: Ohana Health Plan Medicaid |
$963.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$963.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$963.48
|
| Rate for Payer: University Health Alliance Commercial |
$1,672.10
|
|
|
440256240 CLS TRT NAVICULAR FX W MANIP ED Charges
|
Facility
|
IP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 25624
|
| Hospital Charge Code |
440256240
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,949.90 |
| Max. Negotiated Rate |
$2,225.18 |
| Rate for Payer: Cash Price |
$1,491.10
|
| Rate for Payer: Health Management Network Commercial |
$1,949.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,064.60
|
| Rate for Payer: MDX Hawaii PPO |
$2,225.18
|
|
|
440256800 CLS TRT FRACTURE WRIST W MAN ED Charges
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 25680
|
| Hospital Charge Code |
440256800
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.68 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$277.00
|
| Rate for Payer: AlohaCare Medicare |
$232.68
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$509.68
|
| Rate for Payer: Devoted Health Medicare |
$232.68
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$232.68
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$526.30
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Humana Medicare |
$232.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.68
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
| Rate for Payer: Ohana Health Plan Medicaid |
$232.68
|
| Rate for Payer: Ohana Health Plan Medicare |
$232.68
|
| Rate for Payer: UnitedHealthcare Medicare |
$232.68
|
| Rate for Payer: University Health Alliance Commercial |
$403.81
|
|
|
440256800 CLS TRT FRACTURE WRIST W MAN ED Charges
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 25680
|
| Hospital Charge Code |
440256800
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.90 |
| Max. Negotiated Rate |
$537.38 |
| Rate for Payer: Cash Price |
$360.10
|
| Rate for Payer: Health Management Network Commercial |
$470.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$498.60
|
| Rate for Payer: MDX Hawaii PPO |
$537.38
|
|
|
440260370 DECOMPRESSIVE FASCIOTOMY HAND ED Charges
|
Facility
|
OP
|
$6,387.00
|
|
|
Service Code
|
HCPCS 26037
|
| Hospital Charge Code |
440260370
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$6,195.39 |
| Rate for Payer: AlohaCare Medicaid |
$3,193.50
|
| Rate for Payer: AlohaCare Medicare |
$2,682.54
|
| Rate for Payer: Cash Price |
$4,151.55
|
| Rate for Payer: Cash Price |
$4,151.55
|
| Rate for Payer: Cash Price |
$4,151.55
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$5,876.04
|
| Rate for Payer: Devoted Health Medicare |
$2,682.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$417.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$2,682.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$6,067.65
|
| Rate for Payer: Health Management Network Commercial |
$5,428.95
|
| Rate for Payer: Humana Medicare |
$2,682.54
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,748.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$2,682.54
|
| Rate for Payer: MDX Hawaii PPO |
$6,195.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$2,682.54
|
| Rate for Payer: Ohana Health Plan Medicare |
$2,682.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$2,682.54
|
| Rate for Payer: University Health Alliance Commercial |
$4,655.48
|
|
