|
HC REPAIR LIP,<1/2 VERT HEIGHT
|
Facility
|
IP
|
$2,027.00
|
|
|
Service Code
|
HCPCS 40652
|
| Hospital Charge Code |
7614065201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,722.95 |
| Max. Negotiated Rate |
$1,966.19 |
| Rate for Payer: Cash Price |
$1,216.20
|
| Rate for Payer: Health Management Network Commercial |
$1,722.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,824.30
|
| Rate for Payer: MDX Hawaii PPO |
$1,966.19
|
|
|
HC REPAIR LIP,<1/2 VERT HEIGHT
|
Facility
|
OP
|
$2,027.00
|
|
|
Service Code
|
HCPCS 40652
|
| Hospital Charge Code |
7614065201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,966.19 |
| Rate for Payer: AlohaCare Medicaid |
$1,013.50
|
| Rate for Payer: AlohaCare Medicare |
$628.37
|
| Rate for Payer: Cash Price |
$1,216.20
|
| Rate for Payer: Cash Price |
$1,216.20
|
| Rate for Payer: Devoted Health Medicare |
$689.18
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$628.37
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,925.65
|
| Rate for Payer: Health Management Network Commercial |
$1,722.95
|
| Rate for Payer: Humana Medicare |
$628.37
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,824.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$628.37
|
| Rate for Payer: MDX Hawaii PPO |
$1,966.19
|
| Rate for Payer: Ohana Health Plan Medicaid |
$628.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$628.37
|
| Rate for Payer: UnitedHealthcare Medicare |
$628.37
|
| Rate for Payer: University Health Alliance Commercial |
$1,477.48
|
|
|
HC REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT
|
Facility
|
IP
|
$5,772.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
4504065401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$4,906.20 |
| Max. Negotiated Rate |
$5,598.84 |
| Rate for Payer: Cash Price |
$3,463.20
|
| Rate for Payer: Health Management Network Commercial |
$4,906.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,194.80
|
| Rate for Payer: MDX Hawaii PPO |
$5,598.84
|
|
|
HC REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT
|
Facility
|
OP
|
$5,772.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
4504065401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$5,598.84 |
| Rate for Payer: AlohaCare Medicaid |
$2,886.00
|
| Rate for Payer: AlohaCare Medicare |
$1,789.32
|
| Rate for Payer: Cash Price |
$3,463.20
|
| Rate for Payer: Cash Price |
$3,463.20
|
| Rate for Payer: Devoted Health Medicare |
$1,962.48
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,789.32
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$5,483.40
|
| Rate for Payer: Health Management Network Commercial |
$4,906.20
|
| Rate for Payer: Humana Medicare |
$1,789.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$5,194.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,789.32
|
| Rate for Payer: MDX Hawaii PPO |
$5,598.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,789.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,789.32
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,789.32
|
| Rate for Payer: University Health Alliance Commercial |
$4,207.21
|
|
|
HC REPAIR OF PALATE, OVER 2 CM OR REQUIRING COMPLEX REPAIR
|
Facility
|
OP
|
$23,052.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
4504218201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$22,360.44 |
| Rate for Payer: AlohaCare Medicaid |
$11,526.00
|
| Rate for Payer: AlohaCare Medicare |
$7,146.12
|
| Rate for Payer: Cash Price |
$13,831.20
|
| Rate for Payer: Cash Price |
$13,831.20
|
| Rate for Payer: Devoted Health Medicare |
$7,837.68
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$7,146.12
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$21,899.40
|
| Rate for Payer: Health Management Network Commercial |
$19,594.20
|
| Rate for Payer: Humana Medicare |
$7,146.12
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,746.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$7,146.12
|
| Rate for Payer: MDX Hawaii PPO |
$22,360.44
|
| Rate for Payer: Ohana Health Plan Medicaid |
$7,146.12
|
| Rate for Payer: Ohana Health Plan Medicare |
$7,146.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$7,146.12
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
HC REPAIR OF PALATE, OVER 2 CM OR REQUIRING COMPLEX REPAIR
|
Facility
|
IP
|
$23,052.00
|
|
|
Service Code
|
HCPCS 42182
|
| Hospital Charge Code |
4504218201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$19,594.20 |
| Max. Negotiated Rate |
$22,360.44 |
| Rate for Payer: Cash Price |
$13,831.20
|
| Rate for Payer: Health Management Network Commercial |
$19,594.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$20,746.80
|
| Rate for Payer: MDX Hawaii PPO |
$22,360.44
|
|
|
HC REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE
|
Facility
|
IP
|
$27,837.00
|
|
|
Service Code
|
HCPCS 24341
|
| Hospital Charge Code |
4502434101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$23,661.45 |
| Max. Negotiated Rate |
$27,001.89 |
| Rate for Payer: Cash Price |
$16,702.20
|
| Rate for Payer: Health Management Network Commercial |
$23,661.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$25,053.30
|
| Rate for Payer: MDX Hawaii PPO |
$27,001.89
|
|
|
HC REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE
|
Facility
|
OP
|
$27,837.00
|
|
|
Service Code
|
HCPCS 24341
|
| Hospital Charge Code |
4502434101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$27,001.89 |
| Rate for Payer: AlohaCare Medicaid |
$13,918.50
|
| Rate for Payer: AlohaCare Medicare |
$8,629.47
|
| Rate for Payer: Cash Price |
$16,702.20
|
| Rate for Payer: Cash Price |
$16,702.20
|
| Rate for Payer: Devoted Health Medicare |
$9,464.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$8,629.47
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$26,445.15
|
| Rate for Payer: Health Management Network Commercial |
$23,661.45
|
| Rate for Payer: Humana Medicare |
$8,629.47
|
| Rate for Payer: Kaiser Permanente Commercial |
$25,053.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$8,629.47
|
| Rate for Payer: MDX Hawaii PPO |
$27,001.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$8,629.47
|
| Rate for Payer: Ohana Health Plan Medicare |
$8,629.47
|
| Rate for Payer: UnitedHealthcare Medicaid |
$521.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$8,629.47
|
| Rate for Payer: University Health Alliance Commercial |
$6,743.44
|
|
|
HC REPAIR TONGUE LACER,POST 1/3
|
Facility
|
OP
|
$924.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
7614125101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$286.44 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$462.00
|
| Rate for Payer: AlohaCare Medicare |
$286.44
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Devoted Health Medicare |
$314.16
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$286.44
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$877.80
|
| Rate for Payer: Health Management Network Commercial |
$785.40
|
| Rate for Payer: Humana Medicare |
$286.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$831.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$286.44
|
| Rate for Payer: MDX Hawaii PPO |
$896.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$286.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$286.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$286.44
|
| Rate for Payer: University Health Alliance Commercial |
$673.50
|
|
|
HC REPAIR TONGUE LACER,POST 1/3
|
Facility
|
IP
|
$924.00
|
|
|
Service Code
|
HCPCS 41251
|
| Hospital Charge Code |
7614125101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$785.40 |
| Max. Negotiated Rate |
$896.28 |
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Health Management Network Commercial |
$785.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$831.60
|
| Rate for Payer: MDX Hawaii PPO |
$896.28
|
|
|
HC REPOSITION GASTROSTOMY TUBE - GASTROSTOMY TUBE, CHANGE / REPOSITION
|
Facility
|
OP
|
$968.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
7504376101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$300.08 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$484.00
|
| Rate for Payer: AlohaCare Medicare |
$300.08
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Devoted Health Medicare |
$329.12
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$300.08
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$919.60
|
| Rate for Payer: Health Management Network Commercial |
$822.80
|
| Rate for Payer: Humana Medicare |
$300.08
|
| Rate for Payer: Kaiser Permanente Commercial |
$871.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$300.08
|
| Rate for Payer: MDX Hawaii PPO |
$938.96
|
| Rate for Payer: Ohana Health Plan Medicaid |
$300.08
|
| Rate for Payer: Ohana Health Plan Medicare |
$300.08
|
| Rate for Payer: UnitedHealthcare Medicare |
$300.08
|
| Rate for Payer: University Health Alliance Commercial |
$705.58
|
|
|
HC REPOSITION GASTROSTOMY TUBE - GASTROSTOMY TUBE, CHANGE / REPOSITION
|
Facility
|
IP
|
$968.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
7504376101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$822.80 |
| Max. Negotiated Rate |
$938.96 |
| Rate for Payer: Cash Price |
$580.80
|
| Rate for Payer: Health Management Network Commercial |
$822.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$871.20
|
| Rate for Payer: MDX Hawaii PPO |
$938.96
|
|
|
HC REP,SKIN,TRUNK,CMPLX,+5 CM/<
|
Facility
|
OP
|
$1,811.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
7611310201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,756.67 |
| Rate for Payer: AlohaCare Medicaid |
$905.50
|
| Rate for Payer: AlohaCare Medicare |
$561.41
|
| Rate for Payer: Cash Price |
$1,086.60
|
| Rate for Payer: Cash Price |
$1,086.60
|
| Rate for Payer: Devoted Health Medicare |
$615.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$561.41
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,720.45
|
| Rate for Payer: Health Management Network Commercial |
$1,539.35
|
| Rate for Payer: Humana Medicare |
$561.41
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,629.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$561.41
|
| Rate for Payer: MDX Hawaii PPO |
$1,756.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$561.41
|
| Rate for Payer: Ohana Health Plan Medicare |
$561.41
|
| Rate for Payer: UnitedHealthcare Medicare |
$561.41
|
| Rate for Payer: University Health Alliance Commercial |
$1,320.04
|
|
|
HC REP,SKIN,TRUNK,CMPLX,+5 CM/<
|
Facility
|
IP
|
$1,811.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
7611310201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,539.35 |
| Max. Negotiated Rate |
$1,756.67 |
| Rate for Payer: Cash Price |
$1,086.60
|
| Rate for Payer: Health Management Network Commercial |
$1,539.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,629.90
|
| Rate for Payer: MDX Hawaii PPO |
$1,756.67
|
|
|
HC RESUPERF WND BODY <2.5CM
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
4501200101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.21 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$245.21
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$268.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$245.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.21
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.21
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
|
HC RESUPERF WND BODY <2.5CM
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
4501200101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$672.35 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
|
|
HC RESUPERF WND BODY >30 CM
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
7611200701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$672.35 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
|
|
HC RESUPERF WND BODY >30 CM
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 12007
|
| Hospital Charge Code |
7611200701
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.21 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$245.21
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$268.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$245.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.21
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.21
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
|
HC RESUPERF WND BODY 7.6-12.5 CM
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS 12004
|
| Hospital Charge Code |
4501200401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$672.35 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
|
|
HC RESUPERF WND BODY 7.6-12.5 CM
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 12004
|
| Hospital Charge Code |
4501200401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.21 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$245.21
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$268.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$245.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.21
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.21
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
|
HC RESUPERF WND FACE <2.5 CM
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
4501201101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$672.35 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
|
|
HC RESUPERF WND FACE <2.5 CM
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
4501201101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.21 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$245.21
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$268.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$245.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.21
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.21
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
|
HC RESUPERF WND FACE 2.6-5 CM
|
Facility
|
IP
|
$791.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
4501201301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$672.35 |
| Max. Negotiated Rate |
$767.27 |
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
|
|
HC RESUPERF WND FACE 2.6-5 CM
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
4501201301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.21 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$245.21
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$268.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$245.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.21
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.21
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
|
HC RESUPERF WND FACE 5.1-7.5 CM
|
Facility
|
OP
|
$791.00
|
|
|
Service Code
|
HCPCS 12014
|
| Hospital Charge Code |
4501201401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$245.21 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$395.50
|
| Rate for Payer: AlohaCare Medicare |
$245.21
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Cash Price |
$474.60
|
| Rate for Payer: Devoted Health Medicare |
$268.94
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$245.21
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$751.45
|
| Rate for Payer: Health Management Network Commercial |
$672.35
|
| Rate for Payer: Humana Medicare |
$245.21
|
| Rate for Payer: Kaiser Permanente Commercial |
$711.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$245.21
|
| Rate for Payer: MDX Hawaii PPO |
$767.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$245.21
|
| Rate for Payer: Ohana Health Plan Medicare |
$245.21
|
| Rate for Payer: UnitedHealthcare Medicare |
$245.21
|
| Rate for Payer: University Health Alliance Commercial |
$576.56
|
|
