Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

20102-Explore Penetrating Wound Abd/Back

Facility

$8,091.00

Service Code	HCPCS 20102
Hospital Charge Code	8080220
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,848.27
Rate for Payer: AlohaCare Medicaid	$525.09
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: 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: Kaiser Permanente Medicare	$4,045.50
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

20102-Explore Penetrating Wound Abd/Back

Facility

$8,091.00

Service Code	HCPCS 20102
Hospital Charge Code	8080220
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

20103 Exploration of penetrating wound (separate procedure); extremity

Professional

Both

$2,299.00

Service Code	HCPCS 20103
Hospital Charge Code	8037381
Hospital Revenue Code	975
Min. Negotiated Rate	$315.38
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$350.36
Rate for Payer: AlohaCare Medicare	$316.98
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$348.68
Rate for Payer: Hawaii Medical Service Association ABD	$350.36
Rate for Payer: Hawaii Medical Service Association Commercial	$585.10
Rate for Payer: Hawaii Medical Service Association Medicare	$316.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$350.36
Rate for Payer: Hawaii Western Management Group Commercial	$315.38
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$348.68
Rate for Payer: Kaiser Permanente Medicaid	$348.68
Rate for Payer: Kaiser Permanente Medicare	$348.68
Rate for Payer: Ohana Health Plan Medicaid	$350.36
Rate for Payer: Ohana Health Plan Medicare	$316.98
Rate for Payer: UnitedHealthcare Medicaid	$350.36
Rate for Payer: UnitedHealthcare Medicare	$316.98
Rate for Payer: University Health Alliance Commercial	$460.82

20103 EXPLORATION PENETRATING WOUND SPX EXTREMITY TechFee

Facility

$3,863.00

Service Code	HCPCS 20103
Hospital Charge Code	8022745
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,931.50
Rate for Payer: Cash Price	$2,510.95
Rate for Payer: Cash Price	$2,510.95
Rate for Payer: Cash Price	$2,510.95
Rate for Payer: Devoted Health Medicare	$2,124.65
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,931.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,669.85
Rate for Payer: Health Management Network Commercial	$3,283.55
Rate for Payer: Humana Medicare	$1,931.50
Rate for Payer: Kaiser Permanente Commercial	$3,476.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,931.50
Rate for Payer: MDX Hawaii PPO	$3,747.11
Rate for Payer: Ohana Health Plan Medicaid	$1,931.50
Rate for Payer: Ohana Health Plan Medicare	$1,931.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,931.50
Rate for Payer: University Health Alliance Commercial	$2,815.74

20103 EXPLORATION PENETRATING WOUND SPX EXTREMITY TechFee

Facility

$3,863.00

Service Code	HCPCS 20103
Hospital Charge Code	8022745
Hospital Revenue Code	450
Min. Negotiated Rate	$3,283.55
Max. Negotiated Rate	$3,747.11
Rate for Payer: Cash Price	$2,510.95
Rate for Payer: Health Management Network Commercial	$3,283.55
Rate for Payer: Kaiser Permanente Commercial	$3,476.70
Rate for Payer: MDX Hawaii PPO	$3,747.11

20103-Explore Penetrating Wound Extremity

Facility

$3,211.00

Service Code	HCPCS 20103
Hospital Charge Code	8080222
Hospital Revenue Code	450
Min. Negotiated Rate	$2,729.35
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$2,087.15
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: MDX Hawaii PPO	$3,114.67

20103-Explore Penetrating Wound Extremity

Facility

$3,211.00

Service Code	HCPCS 20103
Hospital Charge Code	8080222
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,605.50
Rate for Payer: Cash Price	$2,087.15
Rate for Payer: Cash Price	$2,087.15
Rate for Payer: Cash Price	$2,087.15
Rate for Payer: Devoted Health Medicare	$1,766.05
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,605.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,050.45
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Humana Medicare	$1,605.50
Rate for Payer: Kaiser Permanente Commercial	$2,889.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,605.50
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: Ohana Health Plan Medicaid	$1,605.50
Rate for Payer: Ohana Health Plan Medicare	$1,605.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,605.50
Rate for Payer: University Health Alliance Commercial	$2,340.50

20220 BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS PROCESS, RIB ProFee

Professional

Both

$2,299.00

Service Code	HCPCS 20220
Hospital Charge Code	8016794
Hospital Revenue Code	972
Min. Negotiated Rate	$76.43
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$86.98
Rate for Payer: AlohaCare Medicare	$76.43
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$84.07
Rate for Payer: Hawaii Medical Service Association ABD	$86.98
Rate for Payer: Hawaii Medical Service Association Commercial	$143.37
Rate for Payer: Hawaii Medical Service Association Medicare	$76.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86.98
Rate for Payer: Hawaii Western Management Group Commercial	$89.18
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$84.07
Rate for Payer: Kaiser Permanente Medicaid	$84.07
Rate for Payer: Kaiser Permanente Medicare	$84.07
Rate for Payer: Ohana Health Plan Medicaid	$86.98
Rate for Payer: Ohana Health Plan Medicare	$76.43
Rate for Payer: UnitedHealthcare Medicaid	$86.98
Rate for Payer: UnitedHealthcare Medicare	$76.43
Rate for Payer: University Health Alliance Commercial	$115.07

20220 Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs)

Professional

Both

$2,299.00

Service Code	HCPCS 20220
Hospital Charge Code	8037385
Hospital Revenue Code	975
Min. Negotiated Rate	$76.43
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$86.98
Rate for Payer: AlohaCare Medicare	$76.43
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$84.07
Rate for Payer: Hawaii Medical Service Association ABD	$86.98
Rate for Payer: Hawaii Medical Service Association Commercial	$143.37
Rate for Payer: Hawaii Medical Service Association Medicare	$76.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86.98
Rate for Payer: Hawaii Western Management Group Commercial	$89.18
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$84.07
Rate for Payer: Kaiser Permanente Medicaid	$84.07
Rate for Payer: Kaiser Permanente Medicare	$84.07
Rate for Payer: Ohana Health Plan Medicaid	$86.98
Rate for Payer: Ohana Health Plan Medicare	$76.43
Rate for Payer: UnitedHealthcare Medicaid	$86.98
Rate for Payer: UnitedHealthcare Medicare	$76.43
Rate for Payer: University Health Alliance Commercial	$115.07

20220 CT Biopsy Bone Superficial

Facility

$3,181.00

Service Code	HCPCS 20220
Hospital Charge Code	9882938
Hospital Revenue Code	350
Min. Negotiated Rate	$2,703.85
Max. Negotiated Rate	$3,085.57
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Health Management Network Commercial	$2,703.85
Rate for Payer: Kaiser Permanente Commercial	$2,862.90
Rate for Payer: MDX Hawaii PPO	$3,085.57

20220 CT Biopsy Bone Superficial

Facility

$3,181.00

Service Code	HCPCS 20220
Hospital Charge Code	9882938
Hospital Revenue Code	350
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,590.50
Rate for Payer: AlohaCare Medicare	$1,590.50
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Cash Price	$2,067.65
Rate for Payer: Devoted Health Medicare	$1,749.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,590.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,021.95
Rate for Payer: Health Management Network Commercial	$2,703.85
Rate for Payer: Humana Medicare	$1,590.50
Rate for Payer: Kaiser Permanente Commercial	$2,862.90
Rate for Payer: Kaiser Permanente Medicaid	$1,622.31
Rate for Payer: Kaiser Permanente Medicare	$1,590.50
Rate for Payer: MDX Hawaii PPO	$3,085.57
Rate for Payer: Ohana Health Plan Medicaid	$1,590.50
Rate for Payer: Ohana Health Plan Medicare	$1,590.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,590.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS TechFee

Facility

$1,180.00

Service Code	HCPCS 20550
Hospital Charge Code	8022751
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	$590.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Devoted Health Medicare	$649.00
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	$590.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Humana Medicare	$590.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$590.00
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: Ohana Health Plan Medicaid	$590.00
Rate for Payer: Ohana Health Plan Medicare	$590.00
Rate for Payer: UnitedHealthcare Medicare	$590.00
Rate for Payer: University Health Alliance Commercial	$860.10

20550 INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS TechFee

Facility

$1,180.00

Service Code	HCPCS 20550
Hospital Charge Code	8022751
Hospital Revenue Code	450
Min. Negotiated Rate	$1,003.00
Max. Negotiated Rate	$1,144.60
Rate for Payer: Cash Price	$767.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: MDX Hawaii PPO	$1,144.60

20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar fascia)

Professional

Both

$211.00

Service Code	HCPCS 20550
Hospital Charge Code	8037396
Hospital Revenue Code	975
Min. Negotiated Rate	$32.96
Max. Negotiated Rate	$179.35
Rate for Payer: AlohaCare Medicaid	$38.69
Rate for Payer: AlohaCare Medicare	$32.96
Rate for Payer: Cash Price	$137.15
Rate for Payer: Cash Price	$137.15
Rate for Payer: Devoted Health Medicare	$36.26
Rate for Payer: Hawaii Medical Service Association ABD	$38.69
Rate for Payer: Hawaii Medical Service Association Commercial	$65.18
Rate for Payer: Hawaii Medical Service Association Medicare	$32.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.69
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$179.35
Rate for Payer: Kaiser Permanente Commercial	$36.26
Rate for Payer: Kaiser Permanente Medicaid	$36.26
Rate for Payer: Kaiser Permanente Medicare	$36.26
Rate for Payer: Ohana Health Plan Medicaid	$38.69
Rate for Payer: Ohana Health Plan Medicare	$32.96
Rate for Payer: UnitedHealthcare Medicaid	$38.69
Rate for Payer: UnitedHealthcare Medicare	$32.96
Rate for Payer: University Health Alliance Commercial	$48.22

20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES TechFee

Facility

$677.00

Service Code	HCPCS 20552
Hospital Charge Code	8022752
Hospital Revenue Code	450
Min. Negotiated Rate	$575.45
Max. Negotiated Rate	$656.69
Rate for Payer: Cash Price	$440.05
Rate for Payer: Health Management Network Commercial	$575.45
Rate for Payer: Kaiser Permanente Commercial	$609.30
Rate for Payer: MDX Hawaii PPO	$656.69

20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES TechFee

Facility

$677.00

Service Code	HCPCS 20552
Hospital Charge Code	8022752
Hospital Revenue Code	450
Min. Negotiated Rate	$338.50
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$338.50
Rate for Payer: Cash Price	$440.05
Rate for Payer: Cash Price	$440.05
Rate for Payer: Cash Price	$440.05
Rate for Payer: Devoted Health Medicare	$372.35
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	$338.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$643.15
Rate for Payer: Health Management Network Commercial	$575.45
Rate for Payer: Humana Medicare	$338.50
Rate for Payer: Kaiser Permanente Commercial	$609.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$338.50
Rate for Payer: MDX Hawaii PPO	$656.69
Rate for Payer: Ohana Health Plan Medicaid	$338.50
Rate for Payer: Ohana Health Plan Medicare	$338.50
Rate for Payer: UnitedHealthcare Medicare	$338.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

Professional

Both

$199.00

Service Code	HCPCS 20552
Hospital Charge Code	8037398
Hospital Revenue Code	975
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$169.15
Rate for Payer: AlohaCare Medicaid	$37.23
Rate for Payer: AlohaCare Medicare	$36.40
Rate for Payer: Cash Price	$129.35
Rate for Payer: Cash Price	$129.35
Rate for Payer: Devoted Health Medicare	$40.04
Rate for Payer: Hawaii Medical Service Association ABD	$37.23
Rate for Payer: Hawaii Medical Service Association Commercial	$63.55
Rate for Payer: Hawaii Medical Service Association Medicare	$36.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.23
Rate for Payer: Hawaii Western Management Group Commercial	$59.80
Rate for Payer: Health Management Network Commercial	$169.15
Rate for Payer: Kaiser Permanente Commercial	$40.04
Rate for Payer: Kaiser Permanente Medicaid	$40.04
Rate for Payer: Kaiser Permanente Medicare	$40.04
Rate for Payer: Ohana Health Plan Medicaid	$37.23
Rate for Payer: Ohana Health Plan Medicare	$36.40
Rate for Payer: UnitedHealthcare Medicaid	$37.23
Rate for Payer: UnitedHealthcare Medicare	$36.40
Rate for Payer: University Health Alliance Commercial	$45.72

20552-Inject Trigger Point 1-2 Muscles

Facility

$677.00

Service Code	HCPCS 20552
Hospital Charge Code	8080224
Hospital Revenue Code	761
Min. Negotiated Rate	$35.03
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$338.50
Rate for Payer: AlohaCare Medicare	$338.50
Rate for Payer: Cash Price	$440.05
Rate for Payer: Cash Price	$440.05
Rate for Payer: Cash Price	$440.05
Rate for Payer: Devoted Health Medicare	$372.35
Rate for Payer: Hawaii Medical Service Association Commercial	$392.00
Rate for Payer: Hawaii Medical Service Association Medicare	$338.50
Rate for Payer: Hawaii Western Management Group Commercial	$643.15
Rate for Payer: Health Management Network Commercial	$575.45
Rate for Payer: Humana Medicare	$338.50
Rate for Payer: Kaiser Permanente Commercial	$609.30
Rate for Payer: Kaiser Permanente Medicaid	$345.27
Rate for Payer: Kaiser Permanente Medicare	$338.50
Rate for Payer: MDX Hawaii PPO	$656.69
Rate for Payer: Ohana Health Plan Medicaid	$338.50
Rate for Payer: Ohana Health Plan Medicare	$338.50
Rate for Payer: UnitedHealthcare Medicaid	$35.03
Rate for Payer: UnitedHealthcare Medicare	$338.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

20552-Inject Trigger Point 1-2 Muscles

Facility

$677.00

Service Code	HCPCS 20552
Hospital Charge Code	8080224
Hospital Revenue Code	761
Min. Negotiated Rate	$575.45
Max. Negotiated Rate	$656.69
Rate for Payer: Cash Price	$440.05
Rate for Payer: Health Management Network Commercial	$575.45
Rate for Payer: Kaiser Permanente Commercial	$609.30
Rate for Payer: MDX Hawaii PPO	$656.69

20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES TechFee

Facility

$1,248.00

Service Code	HCPCS 20553
Hospital Charge Code	8022753
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	$624.00
Rate for Payer: Cash Price	$811.20
Rate for Payer: Cash Price	$811.20
Rate for Payer: Cash Price	$811.20
Rate for Payer: Devoted Health Medicare	$686.40
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	$624.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.60
Rate for Payer: Health Management Network Commercial	$1,060.80
Rate for Payer: Humana Medicare	$624.00
Rate for Payer: Kaiser Permanente Commercial	$1,123.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$624.00
Rate for Payer: MDX Hawaii PPO	$1,210.56
Rate for Payer: Ohana Health Plan Medicaid	$624.00
Rate for Payer: Ohana Health Plan Medicare	$624.00
Rate for Payer: UnitedHealthcare Medicare	$624.00
Rate for Payer: University Health Alliance Commercial	$909.67

20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES TechFee

Facility

$1,248.00

Service Code	HCPCS 20553
Hospital Charge Code	8022753
Hospital Revenue Code	450
Min. Negotiated Rate	$1,060.80
Max. Negotiated Rate	$1,210.56
Rate for Payer: Cash Price	$811.20
Rate for Payer: Health Management Network Commercial	$1,060.80
Rate for Payer: Kaiser Permanente Commercial	$1,123.20
Rate for Payer: MDX Hawaii PPO	$1,210.56

20600 ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US TechFee

Facility

$1,180.00

Service Code	HCPCS 20600
Hospital Charge Code	8022754
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	$590.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Devoted Health Medicare	$649.00
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	$590.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Humana Medicare	$590.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$590.00
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: Ohana Health Plan Medicaid	$590.00
Rate for Payer: Ohana Health Plan Medicare	$590.00
Rate for Payer: UnitedHealthcare Medicare	$590.00
Rate for Payer: University Health Alliance Commercial	$860.10

20600 ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US TechFee

Facility

$1,180.00

Service Code	HCPCS 20600
Hospital Charge Code	8022754
Hospital Revenue Code	450
Min. Negotiated Rate	$1,003.00
Max. Negotiated Rate	$1,144.60
Rate for Payer: Cash Price	$767.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: MDX Hawaii PPO	$1,144.60

20600 Drain Inject Joint Bursa Bilat Charges

Facility

$1,180.00

Service Code	HCPCS 20600 50
Hospital Charge Code	8221495
Hospital Revenue Code	761
Min. Negotiated Rate	$40.93
Max. Negotiated Rate	$1,144.60
Rate for Payer: AlohaCare Medicaid	$590.00
Rate for Payer: AlohaCare Medicare	$590.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Cash Price	$767.00
Rate for Payer: Devoted Health Medicare	$649.00
Rate for Payer: Hawaii Medical Service Association Medicare	$590.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Humana Medicare	$590.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: Kaiser Permanente Medicaid	$601.80
Rate for Payer: Kaiser Permanente Medicare	$590.00
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: Ohana Health Plan Medicaid	$590.00
Rate for Payer: Ohana Health Plan Medicare	$590.00
Rate for Payer: UnitedHealthcare Medicaid	$40.93
Rate for Payer: UnitedHealthcare Medicare	$590.00
Rate for Payer: University Health Alliance Commercial	$860.10

20600 Drain Inject Joint Bursa Bilat Charges

Facility

$1,180.00

Service Code	HCPCS 20600 50
Hospital Charge Code	8221495
Hospital Revenue Code	761
Min. Negotiated Rate	$1,003.00
Max. Negotiated Rate	$1,144.60
Rate for Payer: Cash Price	$767.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Kaiser Permanente Commercial	$1,062.00
Rate for Payer: MDX Hawaii PPO	$1,144.60

Know your out-of-pocket cost for care.

All Charges