|
440278310 CLS TRT PRXML TIBFIB DISLOC REQ ANES ED
|
Facility
|
IP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 27831
|
| Hospital Charge Code |
440278310
|
|
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
|
|
|
440278310 CLS TRT PRXML TIBFIB DISLOC REQ ANES ED
|
Facility
|
OP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 27831
|
| Hospital Charge Code |
440278310
|
|
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
|
|
|
440280010 I&D BURSA FOOT ED Charge
|
Facility
|
IP
|
$4,314.00
|
|
|
Service Code
|
HCPCS 28001
|
| Hospital Charge Code |
440280010
|
|
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
|
|
|
440280010 I&D BURSA FOOT ED Charge
|
Facility
|
OP
|
$4,314.00
|
|
|
Service Code
|
HCPCS 28001
|
| Hospital Charge Code |
440280010
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$4,184.58 |
| 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 |
$3,144.47
|
|
|
440281930 REMOVAL FB FOOT COMPLICATED ED Charge
|
Facility
|
IP
|
$3,272.00
|
|
|
Service Code
|
HCPCS 28193
|
| Hospital Charge Code |
440281930
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,781.20 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Health Management Network Commercial |
$2,781.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,944.80
|
| Rate for Payer: MDX Hawaii PPO |
$3,173.84
|
|
|
440281930 REMOVAL FB FOOT COMPLICATED ED Charge
|
Facility
|
OP
|
$3,272.00
|
|
|
Service Code
|
HCPCS 28193
|
| Hospital Charge Code |
440281930
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$340.18 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: AlohaCare Medicaid |
$1,636.00
|
| Rate for Payer: AlohaCare Medicare |
$1,374.24
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Cash Price |
$2,126.80
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$3,010.24
|
| Rate for Payer: Devoted Health Medicare |
$1,374.24
|
| 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 |
$1,374.24
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,108.40
|
| Rate for Payer: Health Management Network Commercial |
$2,781.20
|
| Rate for Payer: Humana Medicare |
$1,374.24
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,944.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,374.24
|
| Rate for Payer: MDX Hawaii PPO |
$3,173.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,374.24
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,374.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$340.18
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,374.24
|
| Rate for Payer: University Health Alliance Commercial |
$2,384.96
|
|
|
440284050 CLS TRT CALCNEAL FX W MAN ED Charge
|
Facility
|
IP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 28405
|
| Hospital Charge Code |
440284050
|
|
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
|
|
|
440284050 CLS TRT CALCNEAL FX W MAN ED Charge
|
Facility
|
OP
|
$2,294.00
|
|
|
Service Code
|
HCPCS 28405
|
| Hospital Charge Code |
440284050
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| 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 Medicare |
$963.48
|
| Rate for Payer: University Health Alliance Commercial |
$1,672.10
|
|
|
440284450 OPN TRT TALUS FX W WO FIXATION ED Charge
|
Facility
|
IP
|
$21,060.00
|
|
|
Service Code
|
HCPCS 28445
|
| Hospital Charge Code |
440284450
|
|
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
|
|
|
440284450 OPN TRT TALUS FX W WO FIXATION ED Charge
|
Facility
|
OP
|
$21,060.00
|
|
|
Service Code
|
HCPCS 28445
|
| Hospital Charge Code |
440284450
|
|
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
|
|
|
440285310 OPN TRT SESMOID FX W WO INTRNL FXTN ED C
|
Facility
|
IP
|
$10,275.00
|
|
|
Service Code
|
HCPCS 28531
|
| Hospital Charge Code |
440285310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$8,733.75 |
| Max. Negotiated Rate |
$9,966.75 |
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Health Management Network Commercial |
$8,733.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,247.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,966.75
|
|
|
440285310 OPN TRT SESMOID FX W WO INTRNL FXTN ED C
|
Facility
|
OP
|
$10,275.00
|
|
|
Service Code
|
HCPCS 28531
|
| Hospital Charge Code |
440285310
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$9,966.75 |
| Rate for Payer: AlohaCare Medicaid |
$5,137.50
|
| Rate for Payer: AlohaCare Medicare |
$4,315.50
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$9,453.00
|
| Rate for Payer: Devoted Health Medicare |
$4,315.50
|
| 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 |
$4,315.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,761.25
|
| Rate for Payer: Health Management Network Commercial |
$8,733.75
|
| Rate for Payer: Humana Medicare |
$4,315.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,247.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,315.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,966.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,315.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,315.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,315.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440285400 TRT TARSAL BONE FX WO MANIP EA ED Charge
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 28540
|
| Hospital Charge Code |
440285400
|
|
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
|
|
|
440285400 TRT TARSAL BONE FX WO MANIP EA ED Charge
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 28540
|
| Hospital Charge Code |
440285400
|
|
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
|
|
|
440285700 DISLOC TALOTRSL W MAN WO ANES ED Charge
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 28570
|
| Hospital Charge Code |
440285700
|
|
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
|
|
|
440285700 DISLOC TALOTRSL W MAN WO ANES ED Charge
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 28570
|
| Hospital Charge Code |
440285700
|
|
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
|
|
|
440285850 OPN TRT TALOTRSL DISLOC INC INT FXTN ED
|
Facility
|
OP
|
$10,275.00
|
|
|
Service Code
|
HCPCS 28585
|
| Hospital Charge Code |
440285850
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$9,966.75 |
| Rate for Payer: AlohaCare Medicaid |
$5,137.50
|
| Rate for Payer: AlohaCare Medicare |
$4,315.50
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$9,453.00
|
| Rate for Payer: Devoted Health Medicare |
$4,315.50
|
| 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 |
$4,315.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,761.25
|
| Rate for Payer: Health Management Network Commercial |
$8,733.75
|
| Rate for Payer: Humana Medicare |
$4,315.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,247.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,315.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,966.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,315.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,315.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,315.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440285850 OPN TRT TALOTRSL DISLOC INC INT FXTN ED
|
Facility
|
IP
|
$10,275.00
|
|
|
Service Code
|
HCPCS 28585
|
| Hospital Charge Code |
440285850
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$8,733.75 |
| Max. Negotiated Rate |
$9,966.75 |
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Health Management Network Commercial |
$8,733.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,247.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,966.75
|
|
|
440286000 DISLOC TALOTRSL WO ANES ED Charge
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
HCPCS 28600
|
| Hospital Charge Code |
440286000
|
|
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
|
|
|
440286000 DISLOC TALOTRSL WO ANES ED Charge
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
HCPCS 28600
|
| Hospital Charge Code |
440286000
|
|
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
|
|
|
440286450 OPN TRT METSLPHLNG DISLOC INC FXTN ED Ch
|
Facility
|
IP
|
$10,275.00
|
|
|
Service Code
|
HCPCS 28645
|
| Hospital Charge Code |
440286450
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$8,733.75 |
| Max. Negotiated Rate |
$9,966.75 |
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Health Management Network Commercial |
$8,733.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,247.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,966.75
|
|
|
440286450 OPN TRT METSLPHLNG DISLOC INC FXTN ED Ch
|
Facility
|
OP
|
$10,275.00
|
|
|
Service Code
|
HCPCS 28645
|
| Hospital Charge Code |
440286450
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$417.00 |
| Max. Negotiated Rate |
$9,966.75 |
| Rate for Payer: AlohaCare Medicaid |
$5,137.50
|
| Rate for Payer: AlohaCare Medicare |
$4,315.50
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Cash Price |
$6,678.75
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$9,453.00
|
| Rate for Payer: Devoted Health Medicare |
$4,315.50
|
| 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 |
$4,315.50
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$9,761.25
|
| Rate for Payer: Health Management Network Commercial |
$8,733.75
|
| Rate for Payer: Humana Medicare |
$4,315.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$9,247.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$4,315.50
|
| Rate for Payer: MDX Hawaii PPO |
$9,966.75
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,315.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,315.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,315.50
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
440286650 CLS INTRPHLNG JNT DISLOC W ANES ED Charg
|
Facility
|
IP
|
$708.00
|
|
|
Service Code
|
HCPCS 28665
|
| Hospital Charge Code |
440286650
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$601.80 |
| Max. Negotiated Rate |
$686.76 |
| Rate for Payer: Cash Price |
$460.20
|
| Rate for Payer: Health Management Network Commercial |
$601.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$637.20
|
| Rate for Payer: MDX Hawaii PPO |
$686.76
|
|
|
440286650 CLS INTRPHLNG JNT DISLOC W ANES ED Charg
|
Facility
|
OP
|
$708.00
|
|
|
Service Code
|
HCPCS 28665
|
| Hospital Charge Code |
440286650
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$297.36 |
| Max. Negotiated Rate |
$4,035.20 |
| Rate for Payer: AlohaCare Medicaid |
$354.00
|
| Rate for Payer: AlohaCare Medicare |
$297.36
|
| Rate for Payer: Cash Price |
$460.20
|
| Rate for Payer: Cash Price |
$460.20
|
| Rate for Payer: Cash Price |
$460.20
|
| Rate for Payer: Deseret Mutual Benefit Administrators Commercial |
$651.36
|
| Rate for Payer: Devoted Health Medicare |
$297.36
|
| 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 |
$297.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$672.60
|
| Rate for Payer: Health Management Network Commercial |
$601.80
|
| Rate for Payer: Humana Medicare |
$297.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$637.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$297.36
|
| Rate for Payer: MDX Hawaii PPO |
$686.76
|
| Rate for Payer: Ohana Health Plan Medicaid |
$297.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$297.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$297.36
|
| Rate for Payer: University Health Alliance Commercial |
$4,035.20
|
|
|
440290490 APPLY CAST FIGURE OF EIGHT ED Charge
|
Facility
|
IP
|
$513.00
|
|
|
Service Code
|
HCPCS 29049
|
| Hospital Charge Code |
440290490
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$436.05 |
| Max. Negotiated Rate |
$497.61 |
| Rate for Payer: Cash Price |
$333.45
|
| Rate for Payer: Health Management Network Commercial |
$436.05
|
| Rate for Payer: Kaiser Permanente Commercial |
$461.70
|
| Rate for Payer: MDX Hawaii PPO |
$497.61
|
|
