Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

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

13120 Repair complex scalp arms and/or legs 1.1 cm to 2.5 cm

Professional

Both

$951.00

Service Code	HCPCS 13120
Hospital Charge Code	8037212
Hospital Revenue Code	975
Min. Negotiated Rate	$190.06
Max. Negotiated Rate	$808.35
Rate for Payer: AlohaCare Medicaid	$240.44
Rate for Payer: AlohaCare Medicare	$204.09
Rate for Payer: Cash Price	$618.15
Rate for Payer: Cash Price	$618.15
Rate for Payer: Devoted Health Medicare	$224.50
Rate for Payer: Hawaii Medical Service Association ABD	$240.44
Rate for Payer: Hawaii Medical Service Association Commercial	$400.84
Rate for Payer: Hawaii Medical Service Association Medicare	$204.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$240.44
Rate for Payer: Hawaii Western Management Group Commercial	$190.06
Rate for Payer: Health Management Network Commercial	$808.35
Rate for Payer: Kaiser Permanente Commercial	$224.50
Rate for Payer: Kaiser Permanente Medicaid	$224.50
Rate for Payer: Kaiser Permanente Medicare	$224.50
Rate for Payer: Ohana Health Plan Medicaid	$240.44
Rate for Payer: Ohana Health Plan Medicare	$204.09
Rate for Payer: UnitedHealthcare Medicaid	$240.44
Rate for Payer: UnitedHealthcare Medicare	$204.09
Rate for Payer: University Health Alliance Commercial	$275.92

13120-Scalp/Arms/Legs 1.1-2.5 cm

Facility

$3,187.00

Service Code	HCPCS 13120
Hospital Charge Code	8080031
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$3,091.39
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,593.50
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Devoted Health Medicare	$1,752.85
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	$1,593.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.65
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Humana Medicare	$1,593.50
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,593.50
Rate for Payer: MDX Hawaii PPO	$3,091.39
Rate for Payer: Ohana Health Plan Medicaid	$1,593.50
Rate for Payer: Ohana Health Plan Medicare	$1,593.50
Rate for Payer: UnitedHealthcare Medicare	$1,593.50
Rate for Payer: University Health Alliance Commercial	$2,323.00

13120-Scalp/Arms/Legs 1.1-2.5 cm

Facility

$3,187.00

Service Code	HCPCS 13120
Hospital Charge Code	8080031
Hospital Revenue Code	450
Min. Negotiated Rate	$2,708.95
Max. Negotiated Rate	$3,091.39
Rate for Payer: Cash Price	$2,071.55
Rate for Payer: Health Management Network Commercial	$2,708.95
Rate for Payer: Kaiser Permanente Commercial	$2,868.30
Rate for Payer: MDX Hawaii PPO	$3,091.39

13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM TechFee

Facility

$3,037.00

Service Code	HCPCS 13121
Hospital Charge Code	8022662
Hospital Revenue Code	450
Min. Negotiated Rate	$2,581.45
Max. Negotiated Rate	$2,945.89
Rate for Payer: Cash Price	$1,974.05
Rate for Payer: Health Management Network Commercial	$2,581.45
Rate for Payer: Kaiser Permanente Commercial	$2,733.30
Rate for Payer: MDX Hawaii PPO	$2,945.89

13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM TechFee

Facility

$3,037.00

Service Code	HCPCS 13121
Hospital Charge Code	8022662
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,518.50
Rate for Payer: Cash Price	$1,974.05
Rate for Payer: Cash Price	$1,974.05
Rate for Payer: Cash Price	$1,974.05
Rate for Payer: Devoted Health Medicare	$1,670.35
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	$1,518.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,885.15
Rate for Payer: Health Management Network Commercial	$2,581.45
Rate for Payer: Humana Medicare	$1,518.50
Rate for Payer: Kaiser Permanente Commercial	$2,733.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,518.50
Rate for Payer: MDX Hawaii PPO	$2,945.89
Rate for Payer: Ohana Health Plan Medicaid	$1,518.50
Rate for Payer: Ohana Health Plan Medicare	$1,518.50
Rate for Payer: UnitedHealthcare Medicare	$1,518.50
Rate for Payer: University Health Alliance Commercial	$5,160.40

13121-Scalp/Arms/Legs 2.6-7.5 cm

Facility

$2,510.00

Service Code	HCPCS 13121
Hospital Charge Code	8080033
Hospital Revenue Code	450
Min. Negotiated Rate	$2,133.50
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: MDX Hawaii PPO	$2,434.70

13121-Scalp/Arms/Legs 2.6-7.5 cm

Facility

$2,510.00

Service Code	HCPCS 13121
Hospital Charge Code	8080033
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,255.00
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Cash Price	$1,631.50
Rate for Payer: Devoted Health Medicare	$1,380.50
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	$1,255.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,384.50
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Humana Medicare	$1,255.00
Rate for Payer: Kaiser Permanente Commercial	$2,259.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,255.00
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: Ohana Health Plan Medicaid	$1,255.00
Rate for Payer: Ohana Health Plan Medicare	$1,255.00
Rate for Payer: UnitedHealthcare Medicare	$1,255.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

13122-Scalp/Arms/Legs Each Addl 5 cm

Facility

$621.00

Service Code	HCPCS 13122
Hospital Charge Code	8080035
Hospital Revenue Code	450
Min. Negotiated Rate	$310.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$310.50
Rate for Payer: Cash Price	$403.65
Rate for Payer: Cash Price	$403.65
Rate for Payer: Cash Price	$403.65
Rate for Payer: Devoted Health Medicare	$341.55
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	$310.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$589.95
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: Humana Medicare	$310.50
Rate for Payer: Kaiser Permanente Commercial	$558.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$310.50
Rate for Payer: MDX Hawaii PPO	$602.37
Rate for Payer: Ohana Health Plan Medicaid	$310.50
Rate for Payer: Ohana Health Plan Medicare	$310.50
Rate for Payer: UnitedHealthcare Medicare	$310.50
Rate for Payer: University Health Alliance Commercial	$452.65

13122-Scalp/Arms/Legs Each Addl 5 cm

Facility

$621.00

Service Code	HCPCS 13122
Hospital Charge Code	8080035
Hospital Revenue Code	450
Min. Negotiated Rate	$527.85
Max. Negotiated Rate	$602.37
Rate for Payer: Cash Price	$403.65
Rate for Payer: Health Management Network Commercial	$527.85
Rate for Payer: Kaiser Permanente Commercial	$558.90
Rate for Payer: MDX Hawaii PPO	$602.37

13131-Face/Neck/Hand/Feet/Genital 1.1-2.5 cm

Facility

$2,286.00

Service Code	HCPCS 13131
Hospital Charge Code	8080026
Hospital Revenue Code	450
Min. Negotiated Rate	$1,943.10
Max. Negotiated Rate	$2,217.42
Rate for Payer: Cash Price	$1,485.90
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Kaiser Permanente Commercial	$2,057.40
Rate for Payer: MDX Hawaii PPO	$2,217.42

13131-Face/Neck/Hand/Feet/Genital 1.1-2.5 cm

Facility

$2,286.00

Service Code	HCPCS 13131
Hospital Charge Code	8080026
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,217.42
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,143.00
Rate for Payer: Cash Price	$1,485.90
Rate for Payer: Cash Price	$1,485.90
Rate for Payer: Cash Price	$1,485.90
Rate for Payer: Devoted Health Medicare	$1,257.30
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	$1,143.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,171.70
Rate for Payer: Health Management Network Commercial	$1,943.10
Rate for Payer: Humana Medicare	$1,143.00
Rate for Payer: Kaiser Permanente Commercial	$2,057.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,143.00
Rate for Payer: MDX Hawaii PPO	$2,217.42
Rate for Payer: Ohana Health Plan Medicaid	$1,143.00
Rate for Payer: Ohana Health Plan Medicare	$1,143.00
Rate for Payer: UnitedHealthcare Medicare	$1,143.00
Rate for Payer: University Health Alliance Commercial	$1,666.27

13131 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM TechFee

Facility

$2,707.00

Service Code	HCPCS 13131
Hospital Charge Code	8022664
Hospital Revenue Code	450
Min. Negotiated Rate	$2,300.95
Max. Negotiated Rate	$2,625.79
Rate for Payer: Cash Price	$1,759.55
Rate for Payer: Health Management Network Commercial	$2,300.95
Rate for Payer: Kaiser Permanente Commercial	$2,436.30
Rate for Payer: MDX Hawaii PPO	$2,625.79

13131 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM TechFee

Facility

$2,707.00

Service Code	HCPCS 13131
Hospital Charge Code	8022664
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,625.79
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,353.50
Rate for Payer: Cash Price	$1,759.55
Rate for Payer: Cash Price	$1,759.55
Rate for Payer: Cash Price	$1,759.55
Rate for Payer: Devoted Health Medicare	$1,488.85
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	$1,353.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,571.65
Rate for Payer: Health Management Network Commercial	$2,300.95
Rate for Payer: Humana Medicare	$1,353.50
Rate for Payer: Kaiser Permanente Commercial	$2,436.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,353.50
Rate for Payer: MDX Hawaii PPO	$2,625.79
Rate for Payer: Ohana Health Plan Medicaid	$1,353.50
Rate for Payer: Ohana Health Plan Medicare	$1,353.50
Rate for Payer: UnitedHealthcare Medicare	$1,353.50
Rate for Payer: University Health Alliance Commercial	$1,973.13

13132-Face/Neck/Hand/Feet/Genital 2.6-7.5 cm

Facility

$2,929.00

Service Code	HCPCS 13132
Hospital Charge Code	8080028
Hospital Revenue Code	450
Min. Negotiated Rate	$2,489.65
Max. Negotiated Rate	$2,841.13
Rate for Payer: Cash Price	$1,903.85
Rate for Payer: Health Management Network Commercial	$2,489.65
Rate for Payer: Kaiser Permanente Commercial	$2,636.10
Rate for Payer: MDX Hawaii PPO	$2,841.13

13132-Face/Neck/Hand/Feet/Genital 2.6-7.5 cm

Facility

$2,929.00

Service Code	HCPCS 13132
Hospital Charge Code	8080028
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,464.50
Rate for Payer: Cash Price	$1,903.85
Rate for Payer: Cash Price	$1,903.85
Rate for Payer: Cash Price	$1,903.85
Rate for Payer: Devoted Health Medicare	$1,610.95
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	$1,464.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,782.55
Rate for Payer: Health Management Network Commercial	$2,489.65
Rate for Payer: Humana Medicare	$1,464.50
Rate for Payer: Kaiser Permanente Commercial	$2,636.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,464.50
Rate for Payer: MDX Hawaii PPO	$2,841.13
Rate for Payer: Ohana Health Plan Medicaid	$1,464.50
Rate for Payer: Ohana Health Plan Medicare	$1,464.50
Rate for Payer: UnitedHealthcare Medicare	$1,464.50
Rate for Payer: University Health Alliance Commercial	$10,679.55

13132 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM TechFee

Facility

$3,561.00

Service Code	HCPCS 13132
Hospital Charge Code	8022665
Hospital Revenue Code	450
Min. Negotiated Rate	$3,026.85
Max. Negotiated Rate	$3,454.17
Rate for Payer: Cash Price	$2,314.65
Rate for Payer: Health Management Network Commercial	$3,026.85
Rate for Payer: Kaiser Permanente Commercial	$3,204.90
Rate for Payer: MDX Hawaii PPO	$3,454.17

13132 REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM TechFee

Facility

$3,561.00

Service Code	HCPCS 13132
Hospital Charge Code	8022665
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,780.50
Rate for Payer: Cash Price	$2,314.65
Rate for Payer: Cash Price	$2,314.65
Rate for Payer: Cash Price	$2,314.65
Rate for Payer: Devoted Health Medicare	$1,958.55
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	$1,780.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,382.95
Rate for Payer: Health Management Network Commercial	$3,026.85
Rate for Payer: Humana Medicare	$1,780.50
Rate for Payer: Kaiser Permanente Commercial	$3,204.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,780.50
Rate for Payer: MDX Hawaii PPO	$3,454.17
Rate for Payer: Ohana Health Plan Medicaid	$1,780.50
Rate for Payer: Ohana Health Plan Medicare	$1,780.50
Rate for Payer: UnitedHealthcare Medicare	$1,780.50
Rate for Payer: University Health Alliance Commercial	$10,679.55

13133-Face/Neck/Hand/Feet/Genital Each Addl 5 cm

Facility

$753.00

Service Code	HCPCS 13133
Hospital Charge Code	8080030
Hospital Revenue Code	450
Min. Negotiated Rate	$640.05
Max. Negotiated Rate	$730.41
Rate for Payer: Cash Price	$489.45
Rate for Payer: Health Management Network Commercial	$640.05
Rate for Payer: Kaiser Permanente Commercial	$677.70
Rate for Payer: MDX Hawaii PPO	$730.41

13133-Face/Neck/Hand/Feet/Genital Each Addl 5 cm

Facility

$753.00

Service Code	HCPCS 13133
Hospital Charge Code	8080030
Hospital Revenue Code	450
Min. Negotiated Rate	$376.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$376.50
Rate for Payer: Cash Price	$489.45
Rate for Payer: Cash Price	$489.45
Rate for Payer: Cash Price	$489.45
Rate for Payer: Devoted Health Medicare	$414.15
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	$376.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$715.35
Rate for Payer: Health Management Network Commercial	$640.05
Rate for Payer: Humana Medicare	$376.50
Rate for Payer: Kaiser Permanente Commercial	$677.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$376.50
Rate for Payer: MDX Hawaii PPO	$730.41
Rate for Payer: Ohana Health Plan Medicaid	$376.50
Rate for Payer: Ohana Health Plan Medicare	$376.50
Rate for Payer: UnitedHealthcare Medicare	$376.50
Rate for Payer: University Health Alliance Commercial	$548.86

13151-Eyes/Ears/Nose/Lip 1.1-2.5 cm

Facility

$2,321.00

Service Code	HCPCS 13151
Hospital Charge Code	8080032
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,251.37
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,160.50
Rate for Payer: Cash Price	$1,508.65
Rate for Payer: Cash Price	$1,508.65
Rate for Payer: Cash Price	$1,508.65
Rate for Payer: Devoted Health Medicare	$1,276.55
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	$1,160.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,204.95
Rate for Payer: Health Management Network Commercial	$1,972.85
Rate for Payer: Humana Medicare	$1,160.50
Rate for Payer: Kaiser Permanente Commercial	$2,088.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,160.50
Rate for Payer: MDX Hawaii PPO	$2,251.37
Rate for Payer: Ohana Health Plan Medicaid	$1,160.50
Rate for Payer: Ohana Health Plan Medicare	$1,160.50
Rate for Payer: UnitedHealthcare Medicare	$1,160.50
Rate for Payer: University Health Alliance Commercial	$1,691.78

13151-Eyes/Ears/Nose/Lip 1.1-2.5 cm

Facility

$2,321.00

Service Code	HCPCS 13151
Hospital Charge Code	8080032
Hospital Revenue Code	450
Min. Negotiated Rate	$1,972.85
Max. Negotiated Rate	$2,251.37
Rate for Payer: Cash Price	$1,508.65
Rate for Payer: Health Management Network Commercial	$1,972.85
Rate for Payer: Kaiser Permanente Commercial	$2,088.90
Rate for Payer: MDX Hawaii PPO	$2,251.37

13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM TechFee

Facility

$2,751.00

Service Code	HCPCS 13151
Hospital Charge Code	8022668
Hospital Revenue Code	450
Min. Negotiated Rate	$2,338.35
Max. Negotiated Rate	$2,668.47
Rate for Payer: Cash Price	$1,788.15
Rate for Payer: Health Management Network Commercial	$2,338.35
Rate for Payer: Kaiser Permanente Commercial	$2,475.90
Rate for Payer: MDX Hawaii PPO	$2,668.47

13151 REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM TechFee

Facility

$2,751.00

Service Code	HCPCS 13151
Hospital Charge Code	8022668
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,668.47
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,375.50
Rate for Payer: Cash Price	$1,788.15
Rate for Payer: Cash Price	$1,788.15
Rate for Payer: Cash Price	$1,788.15
Rate for Payer: Devoted Health Medicare	$1,513.05
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	$1,375.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,613.45
Rate for Payer: Health Management Network Commercial	$2,338.35
Rate for Payer: Humana Medicare	$1,375.50
Rate for Payer: Kaiser Permanente Commercial	$2,475.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,375.50
Rate for Payer: MDX Hawaii PPO	$2,668.47
Rate for Payer: Ohana Health Plan Medicaid	$1,375.50
Rate for Payer: Ohana Health Plan Medicare	$1,375.50
Rate for Payer: UnitedHealthcare Medicare	$1,375.50
Rate for Payer: University Health Alliance Commercial	$2,005.20

13152-Eye/Ear/Nose/Lip 2.6-7.5 cm

Facility

$3,227.00

Service Code	HCPCS 13152
Hospital Charge Code	8080034
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,613.50
Rate for Payer: Cash Price	$2,097.55
Rate for Payer: Cash Price	$2,097.55
Rate for Payer: Cash Price	$2,097.55
Rate for Payer: Devoted Health Medicare	$1,774.85
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	$1,613.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,065.65
Rate for Payer: Health Management Network Commercial	$2,742.95
Rate for Payer: Humana Medicare	$1,613.50
Rate for Payer: Kaiser Permanente Commercial	$2,904.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,613.50
Rate for Payer: MDX Hawaii PPO	$3,130.19
Rate for Payer: Ohana Health Plan Medicaid	$1,613.50
Rate for Payer: Ohana Health Plan Medicare	$1,613.50
Rate for Payer: UnitedHealthcare Medicare	$1,613.50
Rate for Payer: University Health Alliance Commercial	$6,743.44

Know your out-of-pocket cost for care.

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