|
REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 13121
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$218.90 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$264.70
|
| Rate for Payer: AlohaCare Medicare |
$218.90
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$218.90
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$264.70
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$434.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$218.90
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$274.82
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$262.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$262.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$262.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$264.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$218.90
|
| Rate for Payer: UnitedHealthcare Medicaid |
$264.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$218.90
|
| Rate for Payer: University Health Alliance Commercial |
$301.31
|
|
|
REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<
|
Professional
|
Both
|
$409.00
|
|
|
Service Code
|
HCPCS 13122
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$66.77 |
| Max. Negotiated Rate |
$347.65 |
| Rate for Payer: AlohaCare Medicaid |
$82.26
|
| Rate for Payer: AlohaCare Medicare |
$66.77
|
| Rate for Payer: Cash Price |
$265.85
|
| Rate for Payer: Cash Price |
$265.85
|
| Rate for Payer: Devoted Health Medicare |
$66.77
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$82.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$128.19
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$66.77
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$90.48
|
| Rate for Payer: Health Management Network Commercial |
$347.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$80.12
|
| Rate for Payer: Kaiser Permanente Medicaid |
$80.12
|
| Rate for Payer: Kaiser Permanente Medicare |
$80.12
|
| Rate for Payer: Ohana Health Plan Medicaid |
$82.26
|
| Rate for Payer: Ohana Health Plan Medicare |
$66.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$82.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$66.77
|
| Rate for Payer: University Health Alliance Commercial |
$94.86
|
|
|
REPAIR COMPLEX TRUNK 1.1-2.5 CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 13100
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$166.92 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$206.40
|
| Rate for Payer: AlohaCare Medicare |
$174.70
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$174.70
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$206.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$317.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$166.92
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.64
|
| Rate for Payer: Kaiser Permanente Medicaid |
$209.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$206.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$206.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.70
|
| Rate for Payer: University Health Alliance Commercial |
$235.23
|
|
|
REPAIR COMPLEX TRUNK 2.6-7.5 CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 13101
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$215.82 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$255.92
|
| Rate for Payer: AlohaCare Medicare |
$215.82
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$215.82
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$255.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$396.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$215.82
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$237.12
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$258.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$258.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$258.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$255.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$255.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$215.82
|
| Rate for Payer: University Health Alliance Commercial |
$300.06
|
|
|
REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/<
|
Professional
|
Both
|
$336.00
|
|
|
Service Code
|
HCPCS 13102
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$58.71 |
| Max. Negotiated Rate |
$285.60 |
| Rate for Payer: AlohaCare Medicaid |
$71.40
|
| Rate for Payer: AlohaCare Medicare |
$58.71
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Cash Price |
$218.40
|
| Rate for Payer: Devoted Health Medicare |
$58.71
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$71.40
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$112.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$58.71
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.32
|
| Rate for Payer: Health Management Network Commercial |
$285.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.45
|
| Rate for Payer: Kaiser Permanente Medicaid |
$70.45
|
| Rate for Payer: Kaiser Permanente Medicare |
$70.45
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$71.40
|
| Rate for Payer: UnitedHealthcare Medicare |
$58.71
|
| Rate for Payer: University Health Alliance Commercial |
$83.15
|
|
|
REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/<
|
Professional
|
Both
|
$603.00
|
|
|
Service Code
|
HCPCS 13153
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$111.80 |
| Max. Negotiated Rate |
$512.55 |
| Rate for Payer: AlohaCare Medicaid |
$135.86
|
| Rate for Payer: AlohaCare Medicare |
$111.80
|
| Rate for Payer: Cash Price |
$391.95
|
| Rate for Payer: Cash Price |
$391.95
|
| Rate for Payer: Devoted Health Medicare |
$111.80
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$135.86
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$212.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.80
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$137.28
|
| Rate for Payer: Health Management Network Commercial |
$512.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.16
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.16
|
| Rate for Payer: Kaiser Permanente Medicare |
$134.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$135.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.80
|
| Rate for Payer: UnitedHealthcare Medicaid |
$135.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.80
|
| Rate for Payer: University Health Alliance Commercial |
$157.35
|
|
|
REPAIR, EXTENSOR TENDON, FNGR CHARGE
|
Facility
|
OP
|
$6,387.00
|
|
|
Service Code
|
HCPCS 26418
|
| Hospital Charge Code |
440264180
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$10,679.55 |
| 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 |
$10,679.55
|
|
|
REPAIR, EXTENSOR TENDON, FNGR CHARGE
|
Facility
|
IP
|
$6,387.00
|
|
|
Service Code
|
HCPCS 26418
|
| Hospital Charge Code |
440264180
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,428.95 |
| Max. Negotiated Rate |
$6,195.39 |
| Rate for Payer: Cash Price |
$4,151.55
|
| Rate for Payer: Health Management Network Commercial |
$5,428.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,748.30
|
| Rate for Payer: MDX Hawaii PPO |
$6,195.39
|
|
|
REPAIR HAND TENDON CHARGE
|
Facility
|
IP
|
$6,387.00
|
|
|
Service Code
|
HCPCS 26410
|
| Hospital Charge Code |
440264100
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$5,428.95 |
| Max. Negotiated Rate |
$6,195.39 |
| Rate for Payer: Cash Price |
$4,151.55
|
| Rate for Payer: Health Management Network Commercial |
$5,428.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,748.30
|
| Rate for Payer: MDX Hawaii PPO |
$6,195.39
|
|
|
REPAIR HAND TENDON CHARGE
|
Facility
|
OP
|
$6,387.00
|
|
|
Service Code
|
HCPCS 26410
|
| Hospital Charge Code |
440264100
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$6,743.44 |
| 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 |
$6,743.44
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12055
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$298.09 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$307.96
|
| Rate for Payer: AlohaCare Medicare |
$298.09
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$298.09
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$307.96
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$470.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$298.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$301.60
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$357.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$357.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$357.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$307.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$298.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$307.96
|
| Rate for Payer: UnitedHealthcare Medicare |
$298.09
|
| Rate for Payer: University Health Alliance Commercial |
$347.86
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12056
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$301.86 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$395.14
|
| Rate for Payer: AlohaCare Medicare |
$354.93
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$354.93
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$395.14
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$558.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$354.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$301.86
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$425.92
|
| Rate for Payer: Kaiser Permanente Medicaid |
$425.92
|
| Rate for Payer: Kaiser Permanente Medicare |
$425.92
|
| Rate for Payer: Ohana Health Plan Medicaid |
$395.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$354.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$395.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$354.93
|
| Rate for Payer: University Health Alliance Commercial |
$452.68
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12051
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$144.82 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$176.67
|
| Rate for Payer: AlohaCare Medicare |
$153.96
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$153.96
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$176.67
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$269.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$153.96
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.82
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$184.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$184.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$176.67
|
| Rate for Payer: Ohana Health Plan Medicare |
$153.96
|
| Rate for Payer: UnitedHealthcare Medicaid |
$176.67
|
| Rate for Payer: UnitedHealthcare Medicare |
$153.96
|
| Rate for Payer: University Health Alliance Commercial |
$191.81
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12052
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$170.56 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$207.25
|
| Rate for Payer: AlohaCare Medicare |
$177.19
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$177.19
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$207.25
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$316.65
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$177.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$170.56
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.63
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.63
|
| Rate for Payer: Kaiser Permanente Medicare |
$212.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$177.19
|
| Rate for Payer: UnitedHealthcare Medicaid |
$207.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$177.19
|
| Rate for Payer: University Health Alliance Commercial |
$225.61
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12057
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$336.96 |
| Max. Negotiated Rate |
$637.40 |
| Rate for Payer: AlohaCare Medicaid |
$429.09
|
| Rate for Payer: AlohaCare Medicare |
$387.75
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$387.75
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$429.09
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$637.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$387.75
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$336.96
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$465.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$465.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$465.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$429.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$387.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$429.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$387.75
|
| Rate for Payer: University Health Alliance Commercial |
$491.55
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12053
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$191.26 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$222.76
|
| Rate for Payer: AlohaCare Medicare |
$191.26
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$191.26
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$222.76
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$339.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$191.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$193.44
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$229.51
|
| Rate for Payer: Kaiser Permanente Medicaid |
$229.51
|
| Rate for Payer: Kaiser Permanente Medicare |
$229.51
|
| Rate for Payer: Ohana Health Plan Medicaid |
$222.76
|
| Rate for Payer: Ohana Health Plan Medicare |
$191.26
|
| Rate for Payer: UnitedHealthcare Medicaid |
$222.76
|
| Rate for Payer: UnitedHealthcare Medicare |
$191.26
|
| Rate for Payer: University Health Alliance Commercial |
$242.55
|
|
|
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12054
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$198.95 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$224.51
|
| Rate for Payer: AlohaCare Medicare |
$198.95
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$198.95
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$224.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$342.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$198.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$237.64
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$238.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$238.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$238.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$224.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$198.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$224.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$198.95
|
| Rate for Payer: University Health Alliance Commercial |
$253.49
|
|
|
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12045
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$174.46 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$282.29
|
| Rate for Payer: AlohaCare Medicare |
$275.54
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$275.54
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$282.29
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$419.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$275.54
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$174.46
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$330.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$330.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$330.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$282.29
|
| Rate for Payer: Ohana Health Plan Medicare |
$275.54
|
| Rate for Payer: UnitedHealthcare Medicaid |
$282.29
|
| Rate for Payer: UnitedHealthcare Medicare |
$275.54
|
| Rate for Payer: University Health Alliance Commercial |
$319.52
|
|
|
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12041
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$132.93 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$150.87
|
| Rate for Payer: AlohaCare Medicare |
$132.93
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$132.93
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$150.87
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$229.22
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$132.93
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$135.72
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$159.52
|
| Rate for Payer: Kaiser Permanente Medicaid |
$159.52
|
| Rate for Payer: Kaiser Permanente Medicare |
$159.52
|
| Rate for Payer: Ohana Health Plan Medicaid |
$150.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$132.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$150.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$132.93
|
| Rate for Payer: University Health Alliance Commercial |
$164.58
|
|
|
REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 12047
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$269.36 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$356.78
|
| Rate for Payer: AlohaCare Medicare |
$346.92
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$346.92
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$356.78
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$529.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$346.92
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$269.36
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$416.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$416.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$416.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$356.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$346.92
|
| Rate for Payer: UnitedHealthcare Medicaid |
$356.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$346.92
|
| Rate for Payer: University Health Alliance Commercial |
$413.69
|
|
|
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12044
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$190.32 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$220.92
|
| Rate for Payer: AlohaCare Medicare |
$194.42
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$194.42
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$220.92
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$337.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$194.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.32
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$233.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$233.30
|
| Rate for Payer: Kaiser Permanente Medicare |
$233.30
|
| Rate for Payer: Ohana Health Plan Medicaid |
$220.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$194.42
|
| Rate for Payer: UnitedHealthcare Medicaid |
$220.92
|
| Rate for Payer: UnitedHealthcare Medicare |
$194.42
|
| Rate for Payer: University Health Alliance Commercial |
$249.95
|
|
|
REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 12035
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$210.86 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$247.22
|
| Rate for Payer: AlohaCare Medicare |
$228.04
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$228.04
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$247.22
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$380.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$228.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$210.86
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$273.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$273.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$247.22
|
| Rate for Payer: Ohana Health Plan Medicare |
$228.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$247.22
|
| Rate for Payer: UnitedHealthcare Medicare |
$228.04
|
| Rate for Payer: University Health Alliance Commercial |
$269.13
|
|
|
REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 12036
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$265.72 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$285.75
|
| Rate for Payer: AlohaCare Medicare |
$271.61
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$271.61
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$285.75
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$445.20
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$271.61
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$265.72
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$325.93
|
| Rate for Payer: Kaiser Permanente Medicaid |
$325.93
|
| Rate for Payer: Kaiser Permanente Medicare |
$325.93
|
| Rate for Payer: Ohana Health Plan Medicaid |
$285.75
|
| Rate for Payer: Ohana Health Plan Medicare |
$271.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$285.75
|
| Rate for Payer: UnitedHealthcare Medicare |
$271.61
|
| Rate for Payer: University Health Alliance Commercial |
$329.45
|
|
|
REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12031
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$117.26 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$158.83
|
| Rate for Payer: AlohaCare Medicare |
$138.32
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$138.32
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$158.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$242.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$138.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$117.26
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$165.98
|
| Rate for Payer: Kaiser Permanente Medicaid |
$165.98
|
| Rate for Payer: Kaiser Permanente Medicare |
$165.98
|
| Rate for Payer: Ohana Health Plan Medicaid |
$158.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$138.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$158.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$138.32
|
| Rate for Payer: University Health Alliance Commercial |
$172.77
|
|
|
REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12032
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$144.30 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$199.83
|
| Rate for Payer: AlohaCare Medicare |
$171.50
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$171.50
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$199.83
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$303.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$171.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$144.30
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$205.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$205.80
|
| Rate for Payer: Kaiser Permanente Medicare |
$205.80
|
| Rate for Payer: Ohana Health Plan Medicaid |
$199.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$171.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$199.83
|
| Rate for Payer: UnitedHealthcare Medicare |
$171.50
|
| Rate for Payer: University Health Alliance Commercial |
$217.60
|
|
