|
REPAIR INTERMEDIATE S/A/T/E >30.0 CM
|
Professional
|
Both
|
$1,495.00
|
|
|
Service Code
|
HCPCS 12037
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$307.49 |
| Max. Negotiated Rate |
$1,270.75 |
| Rate for Payer: AlohaCare Medicaid |
$330.81
|
| Rate for Payer: AlohaCare Medicare |
$307.49
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Cash Price |
$971.75
|
| Rate for Payer: Devoted Health Medicare |
$307.49
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$330.81
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$514.55
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$307.49
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$318.50
|
| Rate for Payer: Health Management Network Commercial |
$1,270.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$368.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$368.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$368.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$330.81
|
| Rate for Payer: Ohana Health Plan Medicare |
$307.49
|
| Rate for Payer: UnitedHealthcare Medicaid |
$330.81
|
| Rate for Payer: UnitedHealthcare Medicare |
$307.49
|
| Rate for Payer: University Health Alliance Commercial |
$380.76
|
|
|
REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 12034
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$176.54 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$212.66
|
| Rate for Payer: AlohaCare Medicare |
$184.16
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$184.16
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$212.66
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$325.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$184.16
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$176.54
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$220.99
|
| Rate for Payer: Kaiser Permanente Medicaid |
$220.99
|
| Rate for Payer: Kaiser Permanente Medicare |
$220.99
|
| Rate for Payer: Ohana Health Plan Medicaid |
$212.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$184.16
|
| Rate for Payer: UnitedHealthcare Medicaid |
$212.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$184.16
|
| Rate for Payer: University Health Alliance Commercial |
$231.25
|
|
|
REPAIR INTERMEDIATE WOUNDS FACE, EARS, EYELIDS, NO
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
440120560
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$508.50
|
| Rate for Payer: AlohaCare Medicare |
$427.14
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$935.64
|
| Rate for Payer: Devoted Health Medicare |
$427.14
|
| 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 |
$427.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$966.15
|
| Rate for Payer: Health Management Network Commercial |
$864.45
|
| Rate for Payer: Humana Medicare |
$427.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$915.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$427.14
|
| Rate for Payer: MDX Hawaii PPO |
$986.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$427.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$427.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$427.14
|
| Rate for Payer: University Health Alliance Commercial |
$741.29
|
|
|
REPAIR INTERMEDIATE WOUNDS FACE, EARS, EYELIDS, NO
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
440120560
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$864.45 |
| Max. Negotiated Rate |
$986.49 |
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Health Management Network Commercial |
$864.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$915.30
|
| Rate for Payer: MDX Hawaii PPO |
$986.49
|
|
|
REPAIR LIP, FULL THICKNESS CHARGE
|
Facility
|
OP
|
$2,784.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
440406500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$2,700.48 |
| 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 |
$2,029.26
|
|
|
REPAIR LIP, FULL THICKNESS CHARGE
|
Facility
|
IP
|
$2,784.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
440406500
|
|
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 LIP FULL THICKNESS OVER ONE-HALF VERTICAL H
|
Facility
|
IP
|
$2,784.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
440406540
|
|
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 LIP FULL THICKNESS OVER ONE-HALF VERTICAL H
|
Facility
|
OP
|
$2,784.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
440406540
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$2,700.48 |
| 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 Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,169.28
|
| Rate for Payer: University Health Alliance Commercial |
$2,029.26
|
|
|
REPAIR LIP FULL THICKNESS UP TO HALF VERTICAL HEIG
|
Facility
|
IP
|
$2,784.00
|
|
|
Service Code
|
HCPCS 40652
|
| Hospital Charge Code |
440406520
|
|
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 LIP FULL THICKNESS UP TO HALF VERTICAL HEIG
|
Facility
|
OP
|
$2,784.00
|
|
|
Service Code
|
HCPCS 40652
|
| Hospital Charge Code |
440406520
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$2,700.48 |
| 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 |
$2,029.26
|
|
|
REPAIR NAIL BED
|
Professional
|
Both
|
$727.00
|
|
|
Service Code
|
HCPCS 11760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$99.84 |
| Max. Negotiated Rate |
$617.95 |
| Rate for Payer: AlohaCare Medicaid |
$114.03
|
| Rate for Payer: AlohaCare Medicare |
$107.29
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Cash Price |
$472.55
|
| Rate for Payer: Devoted Health Medicare |
$107.29
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$114.03
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$177.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$107.29
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$99.84
|
| Rate for Payer: Health Management Network Commercial |
$617.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$128.75
|
| Rate for Payer: Kaiser Permanente Medicaid |
$128.75
|
| Rate for Payer: Kaiser Permanente Medicare |
$128.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$114.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$107.29
|
| Rate for Payer: UnitedHealthcare Medicaid |
$114.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$107.29
|
| Rate for Payer: University Health Alliance Commercial |
$123.62
|
|
|
Repair of dislocation talotarsal joint; closed
|
Facility
|
OP
|
$6,394.00
|
|
|
Service Code
|
HCPCS 28575
|
| Hospital Charge Code |
440285750
|
|
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
|
|
|
Repair of dislocation talotarsal joint; closed
|
Facility
|
IP
|
$6,394.00
|
|
|
Service Code
|
HCPCS 28575
|
| Hospital Charge Code |
440285750
|
|
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
|
|
|
REPAIR OF LACERATION FLOOR OF MOUTH AND OR ANTERIO
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
HCPCS 41250
|
| Hospital Charge Code |
440412500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$367.20 |
| Max. Negotiated Rate |
$419.04 |
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Health Management Network Commercial |
$367.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$388.80
|
| Rate for Payer: MDX Hawaii PPO |
$419.04
|
|
|
REPAIR OF LACERATION FLOOR OF MOUTH AND OR ANTERIO
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
HCPCS 41250
|
| Hospital Charge Code |
440412500
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$181.44 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$216.00
|
| Rate for Payer: AlohaCare Medicare |
$181.44
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Cash Price |
$280.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$397.44
|
| Rate for Payer: Devoted Health Medicare |
$181.44
|
| 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 |
$181.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$410.40
|
| Rate for Payer: Health Management Network Commercial |
$367.20
|
| Rate for Payer: Humana Medicare |
$181.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$388.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.44
|
| Rate for Payer: MDX Hawaii PPO |
$419.04
|
| Rate for Payer: Ohana Health Plan Medicaid |
$181.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$181.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.44
|
| Rate for Payer: University Health Alliance Commercial |
$314.88
|
|
|
REPAIR OF NAIL BED.
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
440117600
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$508.50
|
| Rate for Payer: AlohaCare Medicare |
$427.14
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$935.64
|
| Rate for Payer: Devoted Health Medicare |
$427.14
|
| 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 |
$427.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$966.15
|
| Rate for Payer: Health Management Network Commercial |
$864.45
|
| Rate for Payer: Humana Medicare |
$427.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$915.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$427.14
|
| Rate for Payer: MDX Hawaii PPO |
$986.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$427.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$427.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$427.14
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
REPAIR OF NAIL BED.
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
440117600
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$864.45 |
| Max. Negotiated Rate |
$986.49 |
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Health Management Network Commercial |
$864.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$915.30
|
| Rate for Payer: MDX Hawaii PPO |
$986.49
|
|
|
REP COMPLX WND, EA ADDTL 5CM CHARGE
|
Facility
|
OP
|
$1,779.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
440131330
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,725.63 |
| Rate for Payer: AlohaCare Medicaid |
$889.50
|
| Rate for Payer: AlohaCare Medicare |
$747.18
|
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$1,636.68
|
| Rate for Payer: Devoted Health Medicare |
$747.18
|
| 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 |
$747.18
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,690.05
|
| Rate for Payer: Health Management Network Commercial |
$1,512.15
|
| Rate for Payer: Humana Medicare |
$747.18
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,601.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$747.18
|
| Rate for Payer: MDX Hawaii PPO |
$1,725.63
|
| Rate for Payer: Ohana Health Plan Medicaid |
$747.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$747.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$747.18
|
| Rate for Payer: University Health Alliance Commercial |
$1,296.71
|
|
|
REP COMPLX WND, EA ADDTL 5CM CHARGE
|
Facility
|
IP
|
$1,779.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
440131330
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,512.15 |
| Max. Negotiated Rate |
$1,725.63 |
| Rate for Payer: Cash Price |
$1,156.35
|
| Rate for Payer: Health Management Network Commercial |
$1,512.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,601.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,725.63
|
|
|
REPR COMPLX WOUND <2.6CM ED Charge
|
Facility
|
IP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
440131310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$864.45 |
| Max. Negotiated Rate |
$986.49 |
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Health Management Network Commercial |
$864.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$915.30
|
| Rate for Payer: MDX Hawaii PPO |
$986.49
|
|
|
REPR COMPLX WOUND <2.6CM ED Charge
|
Facility
|
OP
|
$1,017.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
440131310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$508.50
|
| Rate for Payer: AlohaCare Medicare |
$427.14
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Cash Price |
$661.05
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$935.64
|
| Rate for Payer: Devoted Health Medicare |
$427.14
|
| 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 |
$427.14
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$966.15
|
| Rate for Payer: Health Management Network Commercial |
$864.45
|
| Rate for Payer: Humana Medicare |
$427.14
|
| Rate for Payer: Kaiser Permanente Commercial |
$915.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$427.14
|
| Rate for Payer: MDX Hawaii PPO |
$986.49
|
| Rate for Payer: Ohana Health Plan Medicaid |
$427.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$427.14
|
| Rate for Payer: UnitedHealthcare Medicare |
$427.14
|
| Rate for Payer: University Health Alliance Commercial |
$741.29
|
|
|
Respiratory flow volume loop.
|
Facility
|
IP
|
$662.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
429943750
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$562.70 |
| Max. Negotiated Rate |
$642.14 |
| Rate for Payer: Cash Price |
$430.30
|
| Rate for Payer: Health Management Network Commercial |
$562.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$595.80
|
| Rate for Payer: MDX Hawaii PPO |
$642.14
|
|
|
Respiratory flow volume loop.
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
429943750
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$15.25 |
| Max. Negotiated Rate |
$642.14 |
| Rate for Payer: AlohaCare Medicaid |
$331.00
|
| Rate for Payer: AlohaCare Medicare |
$278.04
|
| Rate for Payer: Cash Price |
$430.30
|
| Rate for Payer: Cash Price |
$430.30
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$609.04
|
| Rate for Payer: Devoted Health Medicare |
$278.04
|
| Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD |
$15.25
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$318.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$278.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$628.90
|
| Rate for Payer: Health Management Network Commercial |
$562.70
|
| Rate for Payer: Humana Medicare |
$278.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$595.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$337.62
|
| Rate for Payer: Kaiser Permanente Medicare |
$278.04
|
| Rate for Payer: MDX Hawaii PPO |
$642.14
|
| Rate for Payer: Ohana Health Plan Medicaid |
$278.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$278.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.25
|
| Rate for Payer: UnitedHealthcare Medicare |
$278.04
|
| Rate for Payer: University Health Alliance Commercial |
$482.53
|
|
|
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC
|
Facility
|
IP
|
$42,142.16
|
|
|
Service Code
|
MSDRG 178
|
| Min. Negotiated Rate |
$42,142.16 |
| Max. Negotiated Rate |
$42,142.16 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42,142.16
|
|
|
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC
|
Facility
|
IP
|
$42,142.16
|
|
|
Service Code
|
MSDRG 177
|
| Min. Negotiated Rate |
$42,142.16 |
| Max. Negotiated Rate |
$42,142.16 |
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42,142.16
|
|
