|
13152-Eye/Ear/Nose/Lip 2.6-7.5 cm
|
Facility
|
OP
|
$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
|
|
|
13153-Eye/Ear/Nose/Lip Each Addl 5 cm
|
Facility
|
OP
|
$809.00
|
|
|
Service Code
|
HCPCS 13153
|
| Hospital Charge Code |
8080036
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$404.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$404.50
|
| Rate for Payer: Cash Price |
$525.85
|
| Rate for Payer: Cash Price |
$525.85
|
| Rate for Payer: Cash Price |
$525.85
|
| Rate for Payer: Devoted Health Medicare |
$444.95
|
| 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 |
$404.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$768.55
|
| Rate for Payer: Health Management Network Commercial |
$687.65
|
| Rate for Payer: Humana Medicare |
$404.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$728.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$404.50
|
| Rate for Payer: MDX Hawaii PPO |
$784.73
|
| Rate for Payer: Ohana Health Plan Medicaid |
$404.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$404.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$404.50
|
| Rate for Payer: University Health Alliance Commercial |
$589.68
|
|
|
13153-Eye/Ear/Nose/Lip Each Addl 5 cm
|
Facility
|
IP
|
$809.00
|
|
|
Service Code
|
HCPCS 13153
|
| Hospital Charge Code |
8080036
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$687.65 |
| Max. Negotiated Rate |
$784.73 |
| Rate for Payer: Cash Price |
$525.85
|
| Rate for Payer: Health Management Network Commercial |
$687.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$728.10
|
| Rate for Payer: MDX Hawaii PPO |
$784.73
|
|
|
14040-Transfer Tissue Head/Hand/Feet Less Than/Equal to 10 cm
|
Facility
|
OP
|
$8,091.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
8080208
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$456.03 |
| Max. Negotiated Rate |
$7,848.27 |
| Rate for Payer: Kaiser Permanente Medicare |
$4,045.50
|
| Rate for Payer: AlohaCare Medicaid |
$901.48
|
| Rate for Payer: AlohaCare Medicare |
$4,045.50
|
| Rate for Payer: Cash Price |
$5,259.15
|
| Rate for Payer: Cash Price |
$5,259.15
|
| Rate for Payer: Devoted Health Medicare |
$4,450.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$848.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$7,085.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$4,045.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$849.21
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$7,686.45
|
| Rate for Payer: Health Management Network Commercial |
$6,877.35
|
| Rate for Payer: Humana Medicare |
$4,045.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,281.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: MDX Hawaii PPO |
$7,848.27
|
| Rate for Payer: Ohana Health Plan Medicaid |
$4,045.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$4,045.50
|
| Rate for Payer: UnitedHealthcare Medicaid |
$456.03
|
| Rate for Payer: UnitedHealthcare Medicare |
$4,045.50
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
14040-Transfer Tissue Head/Hand/Feet Less Than/Equal to 10 cm
|
Facility
|
IP
|
$8,091.00
|
|
|
Service Code
|
HCPCS 14040
|
| Hospital Charge Code |
8080208
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$6,877.35 |
| Max. Negotiated Rate |
$7,848.27 |
| Rate for Payer: Cash Price |
$5,259.15
|
| Rate for Payer: Health Management Network Commercial |
$6,877.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$7,281.90
|
| Rate for Payer: MDX Hawaii PPO |
$7,848.27
|
|
|
15241 Full thickness graft; forehead/cheeks/chin/mouth/neck/axil/gen/hands/feet; ea add 20 sq cm
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
8037249
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$88.09 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: AlohaCare Medicaid |
$106.33
|
| Rate for Payer: AlohaCare Medicare |
$88.09
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Devoted Health Medicare |
$96.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$106.33
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$175.98
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$106.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.66
|
| Rate for Payer: Health Management Network Commercial |
$212.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$96.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$96.90
|
| Rate for Payer: Kaiser Permanente Medicare |
$96.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$106.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.09
|
| Rate for Payer: University Health Alliance Commercial |
$121.13
|
|
|
15260 Full thickness graft, free, direct closure of donor site, nose/ears/eyelids/lips; <20 sq cm
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
8037250
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$686.40 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$884.63
|
| Rate for Payer: AlohaCare Medicare |
$750.78
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$825.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$884.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,451.38
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$750.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$884.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$686.40
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$825.86
|
| Rate for Payer: Kaiser Permanente Medicaid |
$825.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$825.86
|
| Rate for Payer: Ohana Health Plan Medicaid |
$884.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$750.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$884.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$750.78
|
| Rate for Payer: University Health Alliance Commercial |
$999.09
|
|
|
15261 Full thickness graft, free, closure of donor site, nose/ears/eyelids/lips; ea add 20 sq cm
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
8037251
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$112.46 |
| Max. Negotiated Rate |
$229.85 |
| Rate for Payer: AlohaCare Medicaid |
$136.23
|
| Rate for Payer: AlohaCare Medicare |
$112.46
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Devoted Health Medicare |
$123.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$136.23
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$229.85
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$112.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$136.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$150.28
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$123.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$123.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$123.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$136.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$112.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$136.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$112.46
|
| Rate for Payer: University Health Alliance Commercial |
$158.22
|
|
|
15271 Application of skin graft to trunk/arms/legs, up to 100 sq cm; first 25 sq cm
|
Professional
|
Both
|
$1,029.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
8037252
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$74.85 |
| Max. Negotiated Rate |
$874.65 |
| Rate for Payer: AlohaCare Medicaid |
$83.87
|
| Rate for Payer: AlohaCare Medicare |
$74.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Devoted Health Medicare |
$82.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$83.87
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$140.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$83.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$153.40
|
| Rate for Payer: Health Management Network Commercial |
$874.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$82.33
|
| Rate for Payer: Kaiser Permanente Medicaid |
$82.33
|
| Rate for Payer: Kaiser Permanente Medicare |
$82.33
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$83.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.85
|
| Rate for Payer: University Health Alliance Commercial |
$91.51
|
|
|
15272 Application of skin graft to trunk/arms/legs, up to 100 sq cm; ea add 25 sq cm
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
8037253
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: AlohaCare Medicaid |
$16.51
|
| Rate for Payer: AlohaCare Medicare |
$14.31
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Devoted Health Medicare |
$15.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$28.90
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.31
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.12
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$15.74
|
| Rate for Payer: Kaiser Permanente Medicaid |
$15.74
|
| Rate for Payer: Kaiser Permanente Medicare |
$15.74
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.31
|
| Rate for Payer: University Health Alliance Commercial |
$18.02
|
|
|
15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater th
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
8118447
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$168.04 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$191.95
|
| Rate for Payer: AlohaCare Medicare |
$168.04
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$184.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$191.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$347.86
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$168.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$191.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$319.54
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$184.84
|
| Rate for Payer: Kaiser Permanente Medicaid |
$184.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$184.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$191.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$168.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$191.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$168.04
|
| Rate for Payer: University Health Alliance Commercial |
$225.96
|
|
|
15274 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater th
|
Professional
|
Both
|
$122.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
8118448
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$37.70 |
| Max. Negotiated Rate |
$103.70 |
| Rate for Payer: AlohaCare Medicaid |
$43.19
|
| Rate for Payer: AlohaCare Medicare |
$37.70
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Devoted Health Medicare |
$41.47
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$43.19
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$78.91
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$43.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.70
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.47
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.47
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.47
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.70
|
| Rate for Payer: University Health Alliance Commercial |
$51.52
|
|
|
15275 Application of skin graft to face/neck/genitalia/hands/feet, up to 100 sq cm; first 25 sq cm
|
Professional
|
Both
|
$1,029.00
|
|
|
Service Code
|
HCPCS 15275
|
| Hospital Charge Code |
8037254
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$83.83 |
| Max. Negotiated Rate |
$874.65 |
| Rate for Payer: AlohaCare Medicaid |
$93.15
|
| Rate for Payer: AlohaCare Medicare |
$83.83
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Devoted Health Medicare |
$92.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$93.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$155.96
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.83
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$93.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$161.98
|
| Rate for Payer: Health Management Network Commercial |
$874.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$92.21
|
| Rate for Payer: Kaiser Permanente Medicaid |
$92.21
|
| Rate for Payer: Kaiser Permanente Medicare |
$92.21
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.83
|
| Rate for Payer: University Health Alliance Commercial |
$101.92
|
|
|
15276 Application of skin graft to face/neck/genitalia/hands/feet, up to 100 sq cm; ea add 25 sq cm
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
HCPCS 15276
|
| Hospital Charge Code |
8037255
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$21.52 |
| Max. Negotiated Rate |
$42.04 |
| Rate for Payer: AlohaCare Medicaid |
$24.45
|
| Rate for Payer: AlohaCare Medicare |
$21.52
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Devoted Health Medicare |
$23.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$24.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$42.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.66
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$23.67
|
| Rate for Payer: Kaiser Permanente Medicaid |
$23.67
|
| Rate for Payer: Kaiser Permanente Medicare |
$23.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.52
|
| Rate for Payer: University Health Alliance Commercial |
$28.94
|
|
|
15277 App of skin sub grft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, fee
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
8118449
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$193.36 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$218.88
|
| Rate for Payer: AlohaCare Medicare |
$193.36
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$212.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$218.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$374.13
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$193.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$218.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$346.06
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$212.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$212.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$212.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$218.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$193.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$218.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$193.36
|
| Rate for Payer: University Health Alliance Commercial |
$257.54
|
|
|
15278 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit
|
Professional
|
Both
|
$144.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
8118450
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: AlohaCare Medicaid |
$54.23
|
| Rate for Payer: AlohaCare Medicare |
$47.23
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Devoted Health Medicare |
$51.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$54.23
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$93.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$54.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.00
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$51.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$51.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$51.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.23
|
| Rate for Payer: University Health Alliance Commercial |
$64.61
|
|
|
15851 Removal of sutures under anesthesia (other than local), other surgeon
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15851
|
| Hospital Charge Code |
8037302
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$66.78
|
| Rate for Payer: AlohaCare Medicare |
$59.14
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$65.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$66.78
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$75.47
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$59.14
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$66.78
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$46.80
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$65.05
|
| Rate for Payer: Kaiser Permanente Medicaid |
$65.05
|
| Rate for Payer: Kaiser Permanente Medicare |
$65.05
|
| Rate for Payer: Ohana Health Plan Medicaid |
$66.78
|
| Rate for Payer: Ohana Health Plan Medicare |
$59.14
|
| Rate for Payer: UnitedHealthcare Medicaid |
$66.78
|
| Rate for Payer: UnitedHealthcare Medicare |
$59.14
|
| Rate for Payer: University Health Alliance Commercial |
$51.95
|
|
|
15852 Dressing change (for other than burns) under anesthesia (other than local)
|
Professional
|
Both
|
$1,029.00
|
|
|
Service Code
|
HCPCS 15852
|
| Hospital Charge Code |
8037303
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$37.97 |
| Max. Negotiated Rate |
$874.65 |
| Rate for Payer: AlohaCare Medicaid |
$43.86
|
| Rate for Payer: AlohaCare Medicare |
$37.97
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Devoted Health Medicare |
$41.77
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.97
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$58.76
|
| Rate for Payer: Health Management Network Commercial |
$874.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$41.77
|
| Rate for Payer: Kaiser Permanente Medicaid |
$41.77
|
| Rate for Payer: Kaiser Permanente Medicare |
$41.77
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.86
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.97
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.86
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.97
|
|
|
15853, Removal of sutures or staples not requiring anesthesia ProFee
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
HCPCS 15853
|
| Hospital Charge Code |
10925395
|
|
Hospital Revenue Code
|
960
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$23.80 |
| Rate for Payer: AlohaCare Medicaid |
$13.19
|
| Rate for Payer: AlohaCare Medicare |
$15.00
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Devoted Health Medicare |
$16.50
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$15.00
|
| Rate for Payer: Health Management Network Commercial |
$23.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$16.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$16.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$16.50
|
| Rate for Payer: Ohana Health Plan Medicaid |
$13.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$15.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$15.00
|
|
|
16000-Initial Treatment First Degree Burn
|
Facility
|
IP
|
$445.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
8080210
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$378.25 |
| Max. Negotiated Rate |
$431.65 |
| Rate for Payer: Cash Price |
$289.25
|
| Rate for Payer: Health Management Network Commercial |
$378.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$400.50
|
| Rate for Payer: MDX Hawaii PPO |
$431.65
|
|
|
16000-Initial Treatment First Degree Burn
|
Facility
|
OP
|
$445.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
8080210
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$222.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$222.50
|
| Rate for Payer: Cash Price |
$289.25
|
| Rate for Payer: Cash Price |
$289.25
|
| Rate for Payer: Cash Price |
$289.25
|
| Rate for Payer: Devoted Health Medicare |
$244.75
|
| 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 |
$222.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$422.75
|
| Rate for Payer: Health Management Network Commercial |
$378.25
|
| Rate for Payer: Humana Medicare |
$222.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$400.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$222.50
|
| Rate for Payer: MDX Hawaii PPO |
$431.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$222.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$222.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$222.50
|
| Rate for Payer: University Health Alliance Commercial |
$324.36
|
|
|
16000 INITIAL TX 1ST DEGREE BURN LOCAL TX TechFee
|
Facility
|
OP
|
$495.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
8022702
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$247.50 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$247.50
|
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Devoted Health Medicare |
$272.25
|
| 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 |
$247.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$470.25
|
| Rate for Payer: Health Management Network Commercial |
$420.75
|
| Rate for Payer: Humana Medicare |
$247.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$247.50
|
| Rate for Payer: MDX Hawaii PPO |
$480.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$247.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$247.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$247.50
|
| Rate for Payer: University Health Alliance Commercial |
$360.81
|
|
|
16000 INITIAL TX 1ST DEGREE BURN LOCAL TX TechFee
|
Facility
|
IP
|
$495.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
8022702
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$420.75 |
| Max. Negotiated Rate |
$480.15 |
| Rate for Payer: Cash Price |
$321.75
|
| Rate for Payer: Health Management Network Commercial |
$420.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$445.50
|
| Rate for Payer: MDX Hawaii PPO |
$480.15
|
|
|
16020-Burn Dressings/Debridement Small
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
8080212
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$255.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$525.09
|
| Rate for Payer: AlohaCare Medicare |
$255.00
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Devoted Health Medicare |
$280.50
|
| 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 |
$255.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$520.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$484.50
|
| Rate for Payer: Health Management Network Commercial |
$433.50
|
| Rate for Payer: Humana Medicare |
$255.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$459.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$255.00
|
| Rate for Payer: MDX Hawaii PPO |
$494.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$255.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$255.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$255.00
|
| Rate for Payer: University Health Alliance Commercial |
$371.74
|
|
|
16020-Burn Dressings/Debridement Small
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
HCPCS 16020
|
| Hospital Charge Code |
8080212
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$433.50 |
| Max. Negotiated Rate |
$494.70 |
| Rate for Payer: Cash Price |
$331.50
|
| Rate for Payer: Health Management Network Commercial |
$433.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$459.00
|
| Rate for Payer: MDX Hawaii PPO |
$494.70
|
|
