Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

REMOVE NAIL PLATE, EA ADDTL CHARGE

Facility

$611.00

Service Code	HCPCS 11732
Hospital Charge Code	440117320
Hospital Revenue Code	450
Min. Negotiated Rate	$256.62
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$305.50
Rate for Payer: AlohaCare Medicare	$256.62
Rate for Payer: Cash Price	$397.15
Rate for Payer: Cash Price	$397.15
Rate for Payer: Cash Price	$397.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$562.12
Rate for Payer: Devoted Health Medicare	$256.62
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	$256.62
Rate for Payer: Hawaii Western Management Group Commercial	$580.45
Rate for Payer: Health Management Network Commercial	$519.35
Rate for Payer: Humana Medicare	$256.62
Rate for Payer: Kaiser Permanente Commercial	$549.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$256.62
Rate for Payer: MDX Hawaii PPO	$592.67
Rate for Payer: Ohana Health Plan Medicaid	$256.62
Rate for Payer: Ohana Health Plan Medicare	$256.62
Rate for Payer: UnitedHealthcare Medicare	$256.62
Rate for Payer: University Health Alliance Commercial	$445.36

REMOVE NAIL PLATE, EA ADDTL CHARGE

Facility

$611.00

Service Code	HCPCS 11732
Hospital Charge Code	440117320
Hospital Revenue Code	450
Min. Negotiated Rate	$519.35
Max. Negotiated Rate	$592.67
Rate for Payer: Cash Price	$397.15
Rate for Payer: Health Management Network Commercial	$519.35
Rate for Payer: Kaiser Permanente Commercial	$549.90
Rate for Payer: MDX Hawaii PPO	$592.67

RENAL FAILURE WITH CC

Facility

$30,006.73

Service Code	MSDRG 683
Min. Negotiated Rate	$30,006.73
Max. Negotiated Rate	$30,006.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,006.73

RENAL FAILURE WITH MCC

Facility

$30,006.73

Service Code	MSDRG 682
Min. Negotiated Rate	$30,006.73
Max. Negotiated Rate	$30,006.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,006.73

RENAL FAILURE WITHOUT CC/MCC

Facility

$30,006.73

Service Code	MSDRG 684
Min. Negotiated Rate	$30,006.73
Max. Negotiated Rate	$30,006.73
Rate for Payer: Hawaii Medical Service Association Commercial	$30,006.73

Renal Panel 1

Facility

$157.00

Service Code	HCPCS 80069
Hospital Charge Code	422800690
Hospital Revenue Code	301
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$152.29
Rate for Payer: AlohaCare Medicaid	$78.50
Rate for Payer: AlohaCare Medicare	$65.94
Rate for Payer: Cash Price	$102.05
Rate for Payer: Cash Price	$102.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$144.44
Rate for Payer: Devoted Health Medicare	$65.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$12.00
Rate for Payer: Hawaii Medical Service Association Commercial	$10.85
Rate for Payer: Hawaii Medical Service Association Medicare	$65.94
Rate for Payer: Hawaii Western Management Group Commercial	$8.68
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Humana Medicare	$65.94
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: Kaiser Permanente Medicaid	$80.07
Rate for Payer: Kaiser Permanente Medicare	$65.94
Rate for Payer: MDX Hawaii PPO	$152.29
Rate for Payer: Ohana Health Plan Medicaid	$65.94
Rate for Payer: Ohana Health Plan Medicare	$65.94
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: UnitedHealthcare Medicare	$65.94
Rate for Payer: University Health Alliance Commercial	$22.44

Renal Panel 1

Facility

$157.00

Service Code	HCPCS 80069
Hospital Charge Code	422800690
Hospital Revenue Code	301
Min. Negotiated Rate	$133.45
Max. Negotiated Rate	$152.29
Rate for Payer: Cash Price	$102.05
Rate for Payer: Health Management Network Commercial	$133.45
Rate for Payer: Kaiser Permanente Commercial	$141.30
Rate for Payer: MDX Hawaii PPO	$152.29

Renin Activity, Plasma DLS

Facility

$399.00

Service Code	HCPCS 84244
Hospital Charge Code	422842445
Hospital Revenue Code	301
Min. Negotiated Rate	$21.99
Max. Negotiated Rate	$387.03
Rate for Payer: AlohaCare Medicaid	$199.50
Rate for Payer: AlohaCare Medicare	$167.58
Rate for Payer: Cash Price	$259.35
Rate for Payer: Cash Price	$259.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$367.08
Rate for Payer: Devoted Health Medicare	$167.58
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$30.40
Rate for Payer: Hawaii Medical Service Association Commercial	$27.49
Rate for Payer: Hawaii Medical Service Association Medicare	$167.58
Rate for Payer: Hawaii Western Management Group Commercial	$21.99
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Humana Medicare	$167.58
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: Kaiser Permanente Medicaid	$203.49
Rate for Payer: Kaiser Permanente Medicare	$167.58
Rate for Payer: MDX Hawaii PPO	$387.03
Rate for Payer: Ohana Health Plan Medicaid	$167.58
Rate for Payer: Ohana Health Plan Medicare	$167.58
Rate for Payer: UnitedHealthcare Medicaid	$30.40
Rate for Payer: UnitedHealthcare Medicare	$167.58
Rate for Payer: University Health Alliance Commercial	$56.85

Renin Activity, Plasma DLS

Facility

$399.00

Service Code	HCPCS 84244
Hospital Charge Code	422842445
Hospital Revenue Code	301
Min. Negotiated Rate	$339.15
Max. Negotiated Rate	$387.03
Rate for Payer: Cash Price	$259.35
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Kaiser Permanente Commercial	$359.10
Rate for Payer: MDX Hawaii PPO	$387.03

repaglinide 0.5 mg [KMC]

Facility

$3.00

Service Code	NDC 00574024001
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

repaglinide 0.5 mg [KMC]

Facility

$3.00

Service Code	NDC 00574024001
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM

Professional

Both

$1,495.00

Service Code	HCPCS 13151
Hospital Revenue Code	361
Min. Negotiated Rate	$236.40
Max. Negotiated Rate	$1,270.75
Rate for Payer: AlohaCare Medicaid	$284.59
Rate for Payer: AlohaCare Medicare	$236.40
Rate for Payer: Cash Price	$971.75
Rate for Payer: Cash Price	$971.75
Rate for Payer: Devoted Health Medicare	$236.40
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$284.59
Rate for Payer: Hawaii Medical Service Association Commercial	$439.77
Rate for Payer: Hawaii Medical Service Association Medicare	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$282.62
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Kaiser Permanente Commercial	$283.68
Rate for Payer: Kaiser Permanente Medicaid	$283.68
Rate for Payer: Kaiser Permanente Medicare	$283.68
Rate for Payer: Ohana Health Plan Medicaid	$284.59
Rate for Payer: Ohana Health Plan Medicare	$236.40
Rate for Payer: UnitedHealthcare Medicaid	$284.59
Rate for Payer: UnitedHealthcare Medicare	$236.40
Rate for Payer: University Health Alliance Commercial	$325.43

REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM

Professional

Both

$1,495.00

Service Code	HCPCS 13152
Hospital Revenue Code	361
Min. Negotiated Rate	$281.52
Max. Negotiated Rate	$1,270.75
Rate for Payer: AlohaCare Medicaid	$342.30
Rate for Payer: AlohaCare Medicare	$281.52
Rate for Payer: Cash Price	$971.75
Rate for Payer: Cash Price	$971.75
Rate for Payer: Devoted Health Medicare	$281.52
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$342.30
Rate for Payer: Hawaii Medical Service Association Commercial	$552.35
Rate for Payer: Hawaii Medical Service Association Medicare	$281.52
Rate for Payer: Hawaii Western Management Group Commercial	$449.54
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Kaiser Permanente Commercial	$337.82
Rate for Payer: Kaiser Permanente Medicaid	$337.82
Rate for Payer: Kaiser Permanente Medicare	$337.82
Rate for Payer: Ohana Health Plan Medicaid	$342.30
Rate for Payer: Ohana Health Plan Medicare	$281.52
Rate for Payer: UnitedHealthcare Medicaid	$342.30
Rate for Payer: UnitedHealthcare Medicare	$281.52
Rate for Payer: University Health Alliance Commercial	$391.59

REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM

Professional

Both

$727.00

Service Code	HCPCS 13131
Hospital Revenue Code	361
Min. Negotiated Rate	$166.92
Max. Negotiated Rate	$617.95
Rate for Payer: AlohaCare Medicaid	$248.26
Rate for Payer: AlohaCare Medicare	$207.37
Rate for Payer: Cash Price	$472.55
Rate for Payer: Cash Price	$472.55
Rate for Payer: Devoted Health Medicare	$207.37
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$248.26
Rate for Payer: Hawaii Medical Service Association Commercial	$382.94
Rate for Payer: Hawaii Medical Service Association Medicare	$207.37
Rate for Payer: Hawaii Western Management Group Commercial	$166.92
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: Kaiser Permanente Commercial	$248.84
Rate for Payer: Kaiser Permanente Medicaid	$248.84
Rate for Payer: Kaiser Permanente Medicare	$248.84
Rate for Payer: Ohana Health Plan Medicaid	$248.26
Rate for Payer: Ohana Health Plan Medicare	$207.37
Rate for Payer: UnitedHealthcare Medicaid	$248.26
Rate for Payer: UnitedHealthcare Medicare	$207.37
Rate for Payer: University Health Alliance Commercial	$283.37

REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM

Professional

Both

$1,495.00

Service Code	HCPCS 13132
Hospital Revenue Code	361
Min. Negotiated Rate	$254.76
Max. Negotiated Rate	$1,270.75
Rate for Payer: AlohaCare Medicaid	$309.75
Rate for Payer: AlohaCare Medicare	$254.76
Rate for Payer: Cash Price	$971.75
Rate for Payer: Cash Price	$971.75
Rate for Payer: Devoted Health Medicare	$254.76
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$309.75
Rate for Payer: Hawaii Medical Service Association Commercial	$617.50
Rate for Payer: Hawaii Medical Service Association Medicare	$254.76
Rate for Payer: Hawaii Western Management Group Commercial	$401.96
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Kaiser Permanente Commercial	$305.71
Rate for Payer: Kaiser Permanente Medicaid	$305.71
Rate for Payer: Kaiser Permanente Medicare	$305.71
Rate for Payer: Ohana Health Plan Medicaid	$309.75
Rate for Payer: Ohana Health Plan Medicare	$254.76
Rate for Payer: UnitedHealthcare Medicaid	$309.75
Rate for Payer: UnitedHealthcare Medicare	$254.76
Rate for Payer: University Health Alliance Commercial	$353.92

REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<

Professional

Both

$536.00

Service Code	HCPCS 13133
Hospital Revenue Code	361
Min. Negotiated Rate	$101.38
Max. Negotiated Rate	$455.60
Rate for Payer: AlohaCare Medicaid	$125.74
Rate for Payer: AlohaCare Medicare	$101.38
Rate for Payer: Cash Price	$348.40
Rate for Payer: Cash Price	$348.40
Rate for Payer: Devoted Health Medicare	$101.38
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$125.74
Rate for Payer: Hawaii Medical Service Association Commercial	$195.38
Rate for Payer: Hawaii Medical Service Association Medicare	$101.38
Rate for Payer: Hawaii Western Management Group Commercial	$132.86
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Kaiser Permanente Commercial	$121.66
Rate for Payer: Kaiser Permanente Medicaid	$121.66
Rate for Payer: Kaiser Permanente Medicare	$121.66
Rate for Payer: Ohana Health Plan Medicaid	$125.74
Rate for Payer: Ohana Health Plan Medicare	$101.38
Rate for Payer: UnitedHealthcare Medicaid	$125.74
Rate for Payer: UnitedHealthcare Medicare	$101.38
Rate for Payer: University Health Alliance Commercial	$144.58

REPAIR COMPLEX LAC, 2.6-7.5 CM CHARGE

Facility

$2,091.00

Service Code	HCPCS 13132
Hospital Charge Code	440131320
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$1,045.50
Rate for Payer: AlohaCare Medicare	$878.22
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,923.72
Rate for Payer: Devoted Health Medicare	$878.22
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	$878.22
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.45
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Humana Medicare	$878.22
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$878.22
Rate for Payer: MDX Hawaii PPO	$2,028.27
Rate for Payer: Ohana Health Plan Medicaid	$878.22
Rate for Payer: Ohana Health Plan Medicare	$878.22
Rate for Payer: UnitedHealthcare Medicare	$878.22
Rate for Payer: University Health Alliance Commercial	$10,679.55

REPAIR COMPLEX LAC, 2.6-7.5 CM CHARGE

Facility

$2,091.00

Service Code	HCPCS 13132
Hospital Charge Code	440131320
Hospital Revenue Code	450
Min. Negotiated Rate	$1,777.35
Max. Negotiated Rate	$2,028.27
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: MDX Hawaii PPO	$2,028.27

REPAIR COMPLEX LACERATION EYELIDS, EARS, NOSE, AND

Facility

$2,006.00

Service Code	HCPCS 13153
Hospital Charge Code	440131530
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,945.82
Rate for Payer: AlohaCare Medicaid	$1,003.00
Rate for Payer: AlohaCare Medicare	$842.52
Rate for Payer: Cash Price	$1,303.90
Rate for Payer: Cash Price	$1,303.90
Rate for Payer: Cash Price	$1,303.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,845.52
Rate for Payer: Devoted Health Medicare	$842.52
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	$842.52
Rate for Payer: Hawaii Western Management Group Commercial	$1,905.70
Rate for Payer: Health Management Network Commercial	$1,705.10
Rate for Payer: Humana Medicare	$842.52
Rate for Payer: Kaiser Permanente Commercial	$1,805.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$842.52
Rate for Payer: MDX Hawaii PPO	$1,945.82
Rate for Payer: Ohana Health Plan Medicaid	$842.52
Rate for Payer: Ohana Health Plan Medicare	$842.52
Rate for Payer: UnitedHealthcare Medicare	$842.52
Rate for Payer: University Health Alliance Commercial	$1,462.17

REPAIR COMPLEX LACERATION EYELIDS, EARS, NOSE, AND

Facility

$2,006.00

Service Code	HCPCS 13153
Hospital Charge Code	440131530
Hospital Revenue Code	450
Min. Negotiated Rate	$1,705.10
Max. Negotiated Rate	$1,945.82
Rate for Payer: Cash Price	$1,303.90
Rate for Payer: Health Management Network Commercial	$1,705.10
Rate for Payer: Kaiser Permanente Commercial	$1,805.40
Rate for Payer: MDX Hawaii PPO	$1,945.82

REPAIR COMPLEX LACERATION EYELIDS, NOSE, EARS, AND

Facility

$2,091.00

Service Code	HCPCS 13151
Hospital Charge Code	440131510
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$2,028.27
Rate for Payer: AlohaCare Medicaid	$1,045.50
Rate for Payer: AlohaCare Medicare	$878.22
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,923.72
Rate for Payer: Devoted Health Medicare	$878.22
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	$878.22
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.45
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Humana Medicare	$878.22
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$878.22
Rate for Payer: MDX Hawaii PPO	$2,028.27
Rate for Payer: Ohana Health Plan Medicaid	$878.22
Rate for Payer: Ohana Health Plan Medicare	$878.22
Rate for Payer: UnitedHealthcare Medicare	$878.22
Rate for Payer: University Health Alliance Commercial	$1,524.13

REPAIR COMPLEX LACERATION EYELIDS, NOSE, EARS, AND

Facility

$2,091.00

Service Code	HCPCS 13151
Hospital Charge Code	440131510
Hospital Revenue Code	450
Min. Negotiated Rate	$1,777.35
Max. Negotiated Rate	$2,028.27
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: MDX Hawaii PPO	$2,028.27

REPAIR COMPLEX LACERATION TONGUE, FLOOR OF MOUTH >

Facility

$2,784.00

Service Code	HCPCS 41252
Hospital Charge Code	440412520
Hospital Revenue Code	450
Min. Negotiated Rate	$2,366.40
Max. Negotiated Rate	$2,700.48
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Health Management Network Commercial	$2,366.40
Rate for Payer: Kaiser Permanente Commercial	$2,505.60
Rate for Payer: MDX Hawaii PPO	$2,700.48

REPAIR COMPLEX LACERATION TONGUE, FLOOR OF MOUTH >

Facility

$2,784.00

Service Code	HCPCS 41252
Hospital Charge Code	440412520
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,392.00
Rate for Payer: AlohaCare Medicare	$1,169.28
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2,561.28
Rate for Payer: Devoted Health Medicare	$1,169.28
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	$1,169.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,644.80
Rate for Payer: Health Management Network Commercial	$2,366.40
Rate for Payer: Humana Medicare	$1,169.28
Rate for Payer: Kaiser Permanente Commercial	$2,505.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,169.28
Rate for Payer: MDX Hawaii PPO	$2,700.48
Rate for Payer: Ohana Health Plan Medicaid	$1,169.28
Rate for Payer: Ohana Health Plan Medicare	$1,169.28
Rate for Payer: UnitedHealthcare Medicare	$1,169.28
Rate for Payer: University Health Alliance Commercial	$5,160.40

REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM

Professional

Both

$727.00

Service Code	HCPCS 13120
Hospital Revenue Code	361
Min. Negotiated Rate	$190.06
Max. Negotiated Rate	$617.95
Rate for Payer: AlohaCare Medicaid	$240.44
Rate for Payer: AlohaCare Medicare	$204.09
Rate for Payer: Cash Price	$472.55
Rate for Payer: Cash Price	$472.55
Rate for Payer: Devoted Health Medicare	$204.09
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$240.44
Rate for Payer: Hawaii Medical Service Association Commercial	$372.87
Rate for Payer: Hawaii Medical Service Association Medicare	$204.09
Rate for Payer: Hawaii Western Management Group Commercial	$190.06
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: Kaiser Permanente Commercial	$244.91
Rate for Payer: Kaiser Permanente Medicaid	$244.91
Rate for Payer: Kaiser Permanente Medicare	$244.91
Rate for Payer: Ohana Health Plan Medicaid	$240.44
Rate for Payer: Ohana Health Plan Medicare	$204.09
Rate for Payer: UnitedHealthcare Medicaid	$240.44
Rate for Payer: UnitedHealthcare Medicare	$204.09
Rate for Payer: University Health Alliance Commercial	$275.92

Know your out-of-pocket cost for care.

All Charges