Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

10060-I&D Abscess/Cyst/Hematoma Simple

Facility

$746.00

Service Code	HCPCS 10060
Hospital Charge Code	8080043
Hospital Revenue Code	450
Min. Negotiated Rate	$634.10
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$484.90
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: MDX Hawaii PPO	$723.62

10060-I&D Abscess/Cyst/Hematoma Simple

Facility

$746.00

Service Code	HCPCS 10060
Hospital Charge Code	8080043
Hospital Revenue Code	450
Min. Negotiated Rate	$373.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$373.00
Rate for Payer: Cash Price	$484.90
Rate for Payer: Cash Price	$484.90
Rate for Payer: Cash Price	$484.90
Rate for Payer: Devoted Health Medicare	$410.30
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	$373.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$708.70
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Humana Medicare	$373.00
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$373.00
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: Ohana Health Plan Medicaid	$373.00
Rate for Payer: Ohana Health Plan Medicare	$373.00
Rate for Payer: UnitedHealthcare Medicare	$373.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

10060 Incision and drainage of abscess simple or single

Professional

Both

$401.00

Service Code	HCPCS 10060
Hospital Charge Code	8037065
Hospital Revenue Code	975
Min. Negotiated Rate	$66.56
Max. Negotiated Rate	$340.85
Rate for Payer: AlohaCare Medicaid	$114.56
Rate for Payer: AlohaCare Medicare	$106.44
Rate for Payer: Cash Price	$260.65
Rate for Payer: Cash Price	$260.65
Rate for Payer: Devoted Health Medicare	$117.08
Rate for Payer: Hawaii Medical Service Association ABD	$114.56
Rate for Payer: Hawaii Medical Service Association Commercial	$180.98
Rate for Payer: Hawaii Medical Service Association Medicare	$106.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$114.56
Rate for Payer: Hawaii Western Management Group Commercial	$66.56
Rate for Payer: Health Management Network Commercial	$340.85
Rate for Payer: Kaiser Permanente Commercial	$117.08
Rate for Payer: Kaiser Permanente Medicaid	$117.08
Rate for Payer: Kaiser Permanente Medicare	$117.08
Rate for Payer: Ohana Health Plan Medicaid	$114.56
Rate for Payer: Ohana Health Plan Medicare	$106.44
Rate for Payer: UnitedHealthcare Medicaid	$114.56
Rate for Payer: UnitedHealthcare Medicare	$106.44

10061-I&D Abscess/Cyst/Hematoma Complicated

Facility

$810.00

Service Code	HCPCS 10061
Hospital Charge Code	8080045
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

10061-I&D Abscess/Cyst/Hematoma Complicated

Facility

$810.00

Service Code	HCPCS 10061
Hospital Charge Code	8080045
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$4,035.20
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	$4,035.20

10061 Incision and drainage of abscess complicated or multiple

Professional

Both

$683.00

Service Code	HCPCS 10061
Hospital Charge Code	8037066
Hospital Revenue Code	975
Min. Negotiated Rate	$95.42
Max. Negotiated Rate	$580.55
Rate for Payer: AlohaCare Medicaid	$194.24
Rate for Payer: AlohaCare Medicare	$180.01
Rate for Payer: Cash Price	$443.95
Rate for Payer: Cash Price	$443.95
Rate for Payer: Devoted Health Medicare	$198.01
Rate for Payer: Hawaii Medical Service Association ABD	$194.24
Rate for Payer: Hawaii Medical Service Association Medicare	$180.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$194.24
Rate for Payer: Hawaii Western Management Group Commercial	$95.42
Rate for Payer: Health Management Network Commercial	$580.55
Rate for Payer: Kaiser Permanente Commercial	$198.01
Rate for Payer: Kaiser Permanente Medicaid	$198.01
Rate for Payer: Kaiser Permanente Medicare	$198.01
Rate for Payer: Ohana Health Plan Medicaid	$194.24
Rate for Payer: Ohana Health Plan Medicare	$180.01
Rate for Payer: UnitedHealthcare Medicaid	$194.24
Rate for Payer: UnitedHealthcare Medicare	$180.01
Rate for Payer: University Health Alliance Commercial	$209.93

10061 INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE TechFee

Facility

$880.00

Service Code	HCPCS 10061
Hospital Charge Code	8022539
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

10061 INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE TechFee

Facility

$880.00

Service Code	HCPCS 10061
Hospital Charge Code	8022539
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

10080-I&D Pilonidal Cyst Simple

Facility

$3,625.00

Service Code	HCPCS 10080
Hospital Charge Code	8080047
Hospital Revenue Code	450
Min. Negotiated Rate	$3,081.25
Max. Negotiated Rate	$3,516.25
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Health Management Network Commercial	$3,081.25
Rate for Payer: Kaiser Permanente Commercial	$3,262.50
Rate for Payer: MDX Hawaii PPO	$3,516.25

10080-I&D Pilonidal Cyst Simple

Facility

$3,625.00

Service Code	HCPCS 10080
Hospital Charge Code	8080047
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,812.50
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Devoted Health Medicare	$1,993.75
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	$1,812.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,443.75
Rate for Payer: Health Management Network Commercial	$3,081.25
Rate for Payer: Humana Medicare	$1,812.50
Rate for Payer: Kaiser Permanente Commercial	$3,262.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,812.50
Rate for Payer: MDX Hawaii PPO	$3,516.25
Rate for Payer: Ohana Health Plan Medicaid	$1,812.50
Rate for Payer: Ohana Health Plan Medicare	$1,812.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,812.50
Rate for Payer: University Health Alliance Commercial	$4,035.20

10081-I&D Pilonidal Cyst Complicated

Facility

$3,625.00

Service Code	HCPCS 10081
Hospital Charge Code	8080049
Hospital Revenue Code	450
Min. Negotiated Rate	$3,081.25
Max. Negotiated Rate	$3,516.25
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Health Management Network Commercial	$3,081.25
Rate for Payer: Kaiser Permanente Commercial	$3,262.50
Rate for Payer: MDX Hawaii PPO	$3,516.25

10081-I&D Pilonidal Cyst Complicated

Facility

$3,625.00

Service Code	HCPCS 10081
Hospital Charge Code	8080049
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	$1,812.50
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Cash Price	$2,356.25
Rate for Payer: Devoted Health Medicare	$1,993.75
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	$1,812.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$3,443.75
Rate for Payer: Health Management Network Commercial	$3,081.25
Rate for Payer: Humana Medicare	$1,812.50
Rate for Payer: Kaiser Permanente Commercial	$3,262.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,812.50
Rate for Payer: MDX Hawaii PPO	$3,516.25
Rate for Payer: Ohana Health Plan Medicaid	$1,812.50
Rate for Payer: Ohana Health Plan Medicare	$1,812.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,812.50
Rate for Payer: University Health Alliance Commercial	$2,642.26

10120 Incision and removal of foreign body, subcutaneous tissues; simple

Professional

Both

$523.00

Service Code	HCPCS 10120
Hospital Charge Code	8037069
Hospital Revenue Code	975
Min. Negotiated Rate	$59.80
Max. Negotiated Rate	$444.55
Rate for Payer: AlohaCare Medicaid	$113.02
Rate for Payer: AlohaCare Medicare	$108.15
Rate for Payer: Cash Price	$339.95
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$118.97
Rate for Payer: Hawaii Medical Service Association ABD	$113.02
Rate for Payer: Hawaii Medical Service Association Commercial	$172.27
Rate for Payer: Hawaii Medical Service Association Medicare	$108.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$113.02
Rate for Payer: Hawaii Western Management Group Commercial	$59.80
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$118.97
Rate for Payer: Kaiser Permanente Medicaid	$118.97
Rate for Payer: Kaiser Permanente Medicare	$118.97
Rate for Payer: Ohana Health Plan Medicaid	$113.02
Rate for Payer: Ohana Health Plan Medicare	$108.15
Rate for Payer: UnitedHealthcare Medicaid	$113.02
Rate for Payer: UnitedHealthcare Medicare	$108.15
Rate for Payer: University Health Alliance Commercial	$125.09

10120 INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE TechFee

Facility

$880.00

Service Code	HCPCS 10120
Hospital Charge Code	8022542
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

10120 INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE TechFee

Facility

$880.00

Service Code	HCPCS 10120
Hospital Charge Code	8022542
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$5,160.40
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	$5,160.40

10120-Subcutaneous Tissue Simple

Facility

$810.00

Service Code	HCPCS 10120
Hospital Charge Code	8080135
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

10120-Subcutaneous Tissue Simple

Facility

$810.00

Service Code	HCPCS 10120
Hospital Charge Code	8080135
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$5,160.40
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	$5,160.40

10121 Incision and removal of foreign body, subcutaneous tissues; complicated

Professional

Both

$2,299.00

Service Code	HCPCS 10121
Hospital Charge Code	8037070
Hospital Revenue Code	975
Min. Negotiated Rate	$151.06
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$189.71
Rate for Payer: AlohaCare Medicare	$175.90
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$193.49
Rate for Payer: Hawaii Medical Service Association ABD	$189.71
Rate for Payer: Hawaii Medical Service Association Commercial	$314.53
Rate for Payer: Hawaii Medical Service Association Medicare	$175.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$189.71
Rate for Payer: Hawaii Western Management Group Commercial	$151.06
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$193.49
Rate for Payer: Kaiser Permanente Medicaid	$193.49
Rate for Payer: Kaiser Permanente Medicare	$193.49
Rate for Payer: Ohana Health Plan Medicaid	$189.71
Rate for Payer: Ohana Health Plan Medicare	$175.90
Rate for Payer: UnitedHealthcare Medicaid	$189.71
Rate for Payer: UnitedHealthcare Medicare	$175.90
Rate for Payer: University Health Alliance Commercial	$216.52

10121-Subcutaneous Tissue Complex

Facility

$7,249.00

Service Code	HCPCS 10121
Hospital Charge Code	8080137
Hospital Revenue Code	450
Min. Negotiated Rate	$6,161.65
Max. Negotiated Rate	$7,031.53
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Health Management Network Commercial	$6,161.65
Rate for Payer: Kaiser Permanente Commercial	$6,524.10
Rate for Payer: MDX Hawaii PPO	$7,031.53

10121-Subcutaneous Tissue Complex

Facility

$7,249.00

Service Code	HCPCS 10121
Hospital Charge Code	8080137
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,031.53
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$3,624.50
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Cash Price	$4,711.85
Rate for Payer: Devoted Health Medicare	$3,986.95
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	$3,624.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,886.55
Rate for Payer: Health Management Network Commercial	$6,161.65
Rate for Payer: Humana Medicare	$3,624.50
Rate for Payer: Kaiser Permanente Commercial	$6,524.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,624.50
Rate for Payer: MDX Hawaii PPO	$7,031.53
Rate for Payer: Ohana Health Plan Medicaid	$3,624.50
Rate for Payer: Ohana Health Plan Medicare	$3,624.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,624.50
Rate for Payer: University Health Alliance Commercial	$5,160.40

10140-I&D Hematoma/Seroma/Fluid

Facility

$5,584.00

Service Code	HCPCS 10140
Hospital Charge Code	8080051
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,416.48
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$2,792.00
Rate for Payer: Cash Price	$3,629.60
Rate for Payer: Cash Price	$3,629.60
Rate for Payer: Cash Price	$3,629.60
Rate for Payer: Devoted Health Medicare	$3,071.20
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	$2,792.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,304.80
Rate for Payer: Health Management Network Commercial	$4,746.40
Rate for Payer: Humana Medicare	$2,792.00
Rate for Payer: Kaiser Permanente Commercial	$5,025.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,792.00
Rate for Payer: MDX Hawaii PPO	$5,416.48
Rate for Payer: Ohana Health Plan Medicaid	$2,792.00
Rate for Payer: Ohana Health Plan Medicare	$2,792.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,792.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

10140-I&D Hematoma/Seroma/Fluid

Facility

$5,584.00

Service Code	HCPCS 10140
Hospital Charge Code	8080051
Hospital Revenue Code	450
Min. Negotiated Rate	$4,746.40
Max. Negotiated Rate	$5,416.48
Rate for Payer: Cash Price	$3,629.60
Rate for Payer: Health Management Network Commercial	$4,746.40
Rate for Payer: Kaiser Permanente Commercial	$5,025.60
Rate for Payer: MDX Hawaii PPO	$5,416.48

10140 I&D HEMATOMA SEROMA/FLUID COLLECTION TechFee

Facility

$6,830.00

Service Code	HCPCS 10140
Hospital Charge Code	8022544
Hospital Revenue Code	450
Min. Negotiated Rate	$5,805.50
Max. Negotiated Rate	$6,625.10
Rate for Payer: Cash Price	$4,439.50
Rate for Payer: Health Management Network Commercial	$5,805.50
Rate for Payer: Kaiser Permanente Commercial	$6,147.00
Rate for Payer: MDX Hawaii PPO	$6,625.10

10140 I&D HEMATOMA SEROMA/FLUID COLLECTION TechFee

Facility

$6,830.00

Service Code	HCPCS 10140
Hospital Charge Code	8022544
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,625.10
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$3,415.00
Rate for Payer: Cash Price	$4,439.50
Rate for Payer: Cash Price	$4,439.50
Rate for Payer: Cash Price	$4,439.50
Rate for Payer: Devoted Health Medicare	$3,756.50
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	$3,415.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,488.50
Rate for Payer: Health Management Network Commercial	$5,805.50
Rate for Payer: Humana Medicare	$3,415.00
Rate for Payer: Kaiser Permanente Commercial	$6,147.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,415.00
Rate for Payer: MDX Hawaii PPO	$6,625.10
Rate for Payer: Ohana Health Plan Medicaid	$3,415.00
Rate for Payer: Ohana Health Plan Medicare	$3,415.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,415.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

10140 Incision and drainage of hematoma, seroma or fluid collection

Professional

Both

$594.00

Service Code	HCPCS 10140
Hospital Charge Code	8037071
Hospital Revenue Code	975
Min. Negotiated Rate	$47.58
Max. Negotiated Rate	$504.90
Rate for Payer: AlohaCare Medicaid	$124.60
Rate for Payer: AlohaCare Medicare	$120.44
Rate for Payer: Cash Price	$386.10
Rate for Payer: Cash Price	$386.10
Rate for Payer: Devoted Health Medicare	$132.48
Rate for Payer: Hawaii Medical Service Association ABD	$124.60
Rate for Payer: Hawaii Medical Service Association Commercial	$204.11
Rate for Payer: Hawaii Medical Service Association Medicare	$120.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$124.60
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$504.90
Rate for Payer: Kaiser Permanente Commercial	$132.48
Rate for Payer: Kaiser Permanente Medicaid	$132.48
Rate for Payer: Kaiser Permanente Medicare	$132.48
Rate for Payer: Ohana Health Plan Medicaid	$124.60
Rate for Payer: Ohana Health Plan Medicare	$120.44
Rate for Payer: UnitedHealthcare Medicaid	$124.60
Rate for Payer: UnitedHealthcare Medicare	$120.44
Rate for Payer: University Health Alliance Commercial	$140.50

Know your out-of-pocket cost for care.

All Charges