Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

12051 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< TechFee

Facility

$880.00

Service Code	HCPCS 12051
Hospital Charge Code	8022651
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

12051 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< TechFee

Facility

$880.00

Service Code	HCPCS 12051
Hospital Charge Code	8022651
Hospital Revenue Code	450
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

12052-Face/Ear/Eye/Nose/Lip 2.6-5.0 cm

Facility

$810.00

Service Code	HCPCS 12052
Hospital Charge Code	8080013
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$405.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Devoted Health Medicare	$445.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$405.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$769.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Humana Medicare	$405.00
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$405.00
Rate for Payer: MDX Hawaii PPO	$785.70
Rate for Payer: Ohana Health Plan Medicaid	$405.00
Rate for Payer: Ohana Health Plan Medicare	$405.00
Rate for Payer: UnitedHealthcare Medicare	$405.00
Rate for Payer: University Health Alliance Commercial	$590.41

12052-Face/Ear/Eye/Nose/Lip 2.6-5.0 cm

Facility

$810.00

Service Code	HCPCS 12052
Hospital Charge Code	8080013
Hospital Revenue Code	450
Min. Negotiated Rate	$688.50
Max. Negotiated Rate	$785.70
Rate for Payer: Cash Price	$526.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: MDX Hawaii PPO	$785.70

12052 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM TechFee

Facility

$880.00

Service Code	HCPCS 12052
Hospital Charge Code	8022652
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$641.43

12052 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM TechFee

Facility

$880.00

Service Code	HCPCS 12052
Hospital Charge Code	8022652
Hospital Revenue Code	450
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

12053-Face/Ear/Eye/Nose/Lip 5.1-7.5 cm

Facility

$810.00

Service Code	HCPCS 12053
Hospital Charge Code	8080015
Hospital Revenue Code	450
Min. Negotiated Rate	$688.50
Max. Negotiated Rate	$785.70
Rate for Payer: Cash Price	$526.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: MDX Hawaii PPO	$785.70

12053-Face/Ear/Eye/Nose/Lip 5.1-7.5 cm

Facility

$810.00

Service Code	HCPCS 12053
Hospital Charge Code	8080015
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$405.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Devoted Health Medicare	$445.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$405.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$769.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Humana Medicare	$405.00
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$405.00
Rate for Payer: MDX Hawaii PPO	$785.70
Rate for Payer: Ohana Health Plan Medicaid	$405.00
Rate for Payer: Ohana Health Plan Medicare	$405.00
Rate for Payer: UnitedHealthcare Medicare	$405.00
Rate for Payer: University Health Alliance Commercial	$590.41

12053 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM TechFee

Facility

$880.00

Service Code	HCPCS 12053
Hospital Charge Code	8022653
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$641.43

12053 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM TechFee

Facility

$880.00

Service Code	HCPCS 12053
Hospital Charge Code	8022653
Hospital Revenue Code	450
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

12054-Face/Ear/Eye/Nose/Lip 7.6-12.5 cm

Facility

$810.00

Service Code	HCPCS 12054
Hospital Charge Code	8080017
Hospital Revenue Code	450
Min. Negotiated Rate	$688.50
Max. Negotiated Rate	$785.70
Rate for Payer: Cash Price	$526.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: MDX Hawaii PPO	$785.70

12054-Face/Ear/Eye/Nose/Lip 7.6-12.5 cm

Facility

$810.00

Service Code	HCPCS 12054
Hospital Charge Code	8080017
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$405.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cash Price	$526.50
Rate for Payer: Devoted Health Medicare	$445.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$405.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$769.50
Rate for Payer: Health Management Network Commercial	$688.50
Rate for Payer: Humana Medicare	$405.00
Rate for Payer: Kaiser Permanente Commercial	$729.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$405.00
Rate for Payer: MDX Hawaii PPO	$785.70
Rate for Payer: Ohana Health Plan Medicaid	$405.00
Rate for Payer: Ohana Health Plan Medicare	$405.00
Rate for Payer: UnitedHealthcare Medicare	$405.00
Rate for Payer: University Health Alliance Commercial	$590.41

12054 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM TechFee

Facility

$880.00

Service Code	HCPCS 12054
Hospital Charge Code	8022654
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$641.43

12054 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM TechFee

Facility

$880.00

Service Code	HCPCS 12054
Hospital Charge Code	8022654
Hospital Revenue Code	450
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

12055-Face/Ear/Eye/Nose/Lip 12.6-20.0 cm

Facility

$1,984.00

Service Code	HCPCS 12055
Hospital Charge Code	8080019
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,924.48
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$992.00
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Devoted Health Medicare	$1,091.20
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$992.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,884.80
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Humana Medicare	$992.00
Rate for Payer: Kaiser Permanente Commercial	$1,785.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$992.00
Rate for Payer: MDX Hawaii PPO	$1,924.48
Rate for Payer: Ohana Health Plan Medicaid	$992.00
Rate for Payer: Ohana Health Plan Medicare	$992.00
Rate for Payer: UnitedHealthcare Medicare	$992.00
Rate for Payer: University Health Alliance Commercial	$1,446.14

12055-Face/Ear/Eye/Nose/Lip 12.6-20.0 cm

Facility

$1,984.00

Service Code	HCPCS 12055
Hospital Charge Code	8080019
Hospital Revenue Code	450
Min. Negotiated Rate	$1,686.40
Max. Negotiated Rate	$1,924.48
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Kaiser Permanente Commercial	$1,785.60
Rate for Payer: MDX Hawaii PPO	$1,924.48

12056-Face/Ear/Eye/Nose/Lip 20.1-30.0 cm

Facility

$1,595.00

Service Code	HCPCS 12056
Hospital Charge Code	8080021
Hospital Revenue Code	450
Min. Negotiated Rate	$1,355.75
Max. Negotiated Rate	$1,547.15
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Health Management Network Commercial	$1,355.75
Rate for Payer: Kaiser Permanente Commercial	$1,435.50
Rate for Payer: MDX Hawaii PPO	$1,547.15

12056-Face/Ear/Eye/Nose/Lip 20.1-30.0 cm

Facility

$1,595.00

Service Code	HCPCS 12056
Hospital Charge Code	8080021
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$797.50
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Devoted Health Medicare	$877.25
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$797.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,515.25
Rate for Payer: Health Management Network Commercial	$1,355.75
Rate for Payer: Humana Medicare	$797.50
Rate for Payer: Kaiser Permanente Commercial	$1,435.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$797.50
Rate for Payer: MDX Hawaii PPO	$1,547.15
Rate for Payer: Ohana Health Plan Medicaid	$797.50
Rate for Payer: Ohana Health Plan Medicare	$797.50
Rate for Payer: UnitedHealthcare Medicare	$797.50
Rate for Payer: University Health Alliance Commercial	$1,162.60

12057-Face/Ear/Eye/Nose/Lip Greater Than 30.0 cm

Facility

$1,595.00

Service Code	HCPCS 12057
Hospital Charge Code	8080023
Hospital Revenue Code	450
Min. Negotiated Rate	$1,355.75
Max. Negotiated Rate	$1,547.15
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Health Management Network Commercial	$1,355.75
Rate for Payer: Kaiser Permanente Commercial	$1,435.50
Rate for Payer: MDX Hawaii PPO	$1,547.15

12057-Face/Ear/Eye/Nose/Lip Greater Than 30.0 cm

Facility

$1,595.00

Service Code	HCPCS 12057
Hospital Charge Code	8080023
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$797.50
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Cash Price	$1,036.75
Rate for Payer: Devoted Health Medicare	$877.25
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$797.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,515.25
Rate for Payer: Health Management Network Commercial	$1,355.75
Rate for Payer: Humana Medicare	$797.50
Rate for Payer: Kaiser Permanente Commercial	$1,435.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$797.50
Rate for Payer: MDX Hawaii PPO	$1,547.15
Rate for Payer: Ohana Health Plan Medicaid	$797.50
Rate for Payer: Ohana Health Plan Medicare	$797.50
Rate for Payer: UnitedHealthcare Medicare	$797.50
Rate for Payer: University Health Alliance Commercial	$1,162.60

13100-Trunk 1.1-2.5 cm

Facility

$3,028.00

Service Code	HCPCS 13100
Hospital Charge Code	8080025
Hospital Revenue Code	450
Min. Negotiated Rate	$2,573.80
Max. Negotiated Rate	$2,937.16
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Health Management Network Commercial	$2,573.80
Rate for Payer: Kaiser Permanente Commercial	$2,725.20
Rate for Payer: MDX Hawaii PPO	$2,937.16

13100-Trunk 1.1-2.5 cm

Facility

$3,028.00

Service Code	HCPCS 13100
Hospital Charge Code	8080025
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,937.16
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,514.00
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Devoted Health Medicare	$1,665.40
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,514.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,876.60
Rate for Payer: Health Management Network Commercial	$2,573.80
Rate for Payer: Humana Medicare	$1,514.00
Rate for Payer: Kaiser Permanente Commercial	$2,725.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,514.00
Rate for Payer: MDX Hawaii PPO	$2,937.16
Rate for Payer: Ohana Health Plan Medicaid	$1,514.00
Rate for Payer: Ohana Health Plan Medicare	$1,514.00
Rate for Payer: UnitedHealthcare Medicare	$1,514.00
Rate for Payer: University Health Alliance Commercial	$2,207.11

13101-Trunk 2.6-7.5 cm

Facility

$3,028.00

Service Code	HCPCS 13101
Hospital Charge Code	8080027
Hospital Revenue Code	450
Min. Negotiated Rate	$2,573.80
Max. Negotiated Rate	$2,937.16
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Health Management Network Commercial	$2,573.80
Rate for Payer: Kaiser Permanente Commercial	$2,725.20
Rate for Payer: MDX Hawaii PPO	$2,937.16

13101-Trunk 2.6-7.5 cm

Facility

$3,028.00

Service Code	HCPCS 13101
Hospital Charge Code	8080027
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,937.16
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,514.00
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Cash Price	$1,968.20
Rate for Payer: Devoted Health Medicare	$1,665.40
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,514.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,876.60
Rate for Payer: Health Management Network Commercial	$2,573.80
Rate for Payer: Humana Medicare	$1,514.00
Rate for Payer: Kaiser Permanente Commercial	$2,725.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,514.00
Rate for Payer: MDX Hawaii PPO	$2,937.16
Rate for Payer: Ohana Health Plan Medicaid	$1,514.00
Rate for Payer: Ohana Health Plan Medicare	$1,514.00
Rate for Payer: UnitedHealthcare Medicare	$1,514.00
Rate for Payer: University Health Alliance Commercial	$2,207.11

13102-Trunk Each Addl 5 cm

Facility

$1,011.00

Service Code	HCPCS 13102
Hospital Charge Code	8080029
Hospital Revenue Code	450
Min. Negotiated Rate	$505.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$505.50
Rate for Payer: Cash Price	$657.15
Rate for Payer: Cash Price	$657.15
Rate for Payer: Cash Price	$657.15
Rate for Payer: Devoted Health Medicare	$556.05
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$505.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$960.45
Rate for Payer: Health Management Network Commercial	$859.35
Rate for Payer: Humana Medicare	$505.50
Rate for Payer: Kaiser Permanente Commercial	$909.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$505.50
Rate for Payer: MDX Hawaii PPO	$980.67
Rate for Payer: Ohana Health Plan Medicaid	$505.50
Rate for Payer: Ohana Health Plan Medicare	$505.50
Rate for Payer: UnitedHealthcare Medicare	$505.50
Rate for Payer: University Health Alliance Commercial	$736.92

Know your out-of-pocket cost for care.

All Charges