Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

38221 Bone Marrow Biopsy Bilat TechFee

Facility

$3,863.00

Service Code	HCPCS 38221
Hospital Charge Code	8343976
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$3,747.11
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	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,931.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
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

38221 Bone Marrow Biopsy Bilat TechFee

Facility

$3,863.00

Service Code	HCPCS 38221
Hospital Charge Code	8343976
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

38500 Biopsy or excision of lymph node(s); open, superficial

Professional

Both

$5,449.00

Service Code	HCPCS 38500
Hospital Charge Code	8039058
Hospital Revenue Code	975
Min. Negotiated Rate	$179.40
Max. Negotiated Rate	$4,631.65
Rate for Payer: AlohaCare Medicaid	$258.09
Rate for Payer: AlohaCare Medicare	$245.42
Rate for Payer: Cash Price	$3,541.85
Rate for Payer: Cash Price	$3,541.85
Rate for Payer: Devoted Health Medicare	$269.96
Rate for Payer: Hawaii Medical Service Association ABD	$258.09
Rate for Payer: Hawaii Medical Service Association Commercial	$434.01
Rate for Payer: Hawaii Medical Service Association Medicare	$245.42
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.09
Rate for Payer: Hawaii Western Management Group Commercial	$179.40
Rate for Payer: Health Management Network Commercial	$4,631.65
Rate for Payer: Kaiser Permanente Commercial	$269.96
Rate for Payer: Kaiser Permanente Medicaid	$269.96
Rate for Payer: Kaiser Permanente Medicare	$269.96
Rate for Payer: Ohana Health Plan Medicaid	$258.09
Rate for Payer: Ohana Health Plan Medicare	$245.42
Rate for Payer: UnitedHealthcare Medicaid	$258.09
Rate for Payer: UnitedHealthcare Medicare	$245.42
Rate for Payer: University Health Alliance Commercial	$341.82

38505 BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, A ProFee

Professional

Both

$2,299.00

Service Code	HCPCS 38505
Hospital Charge Code	8019497
Hospital Revenue Code	972
Min. Negotiated Rate	$74.81
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$85.75
Rate for Payer: AlohaCare Medicare	$74.81
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$82.29
Rate for Payer: Hawaii Medical Service Association ABD	$85.75
Rate for Payer: Hawaii Medical Service Association Commercial	$140.72
Rate for Payer: Hawaii Medical Service Association Medicare	$74.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.75
Rate for Payer: Hawaii Western Management Group Commercial	$105.30
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$82.29
Rate for Payer: Kaiser Permanente Medicaid	$82.29
Rate for Payer: Kaiser Permanente Medicare	$82.29
Rate for Payer: Ohana Health Plan Medicaid	$85.75
Rate for Payer: Ohana Health Plan Medicare	$74.81
Rate for Payer: UnitedHealthcare Medicaid	$85.75
Rate for Payer: UnitedHealthcare Medicare	$74.81
Rate for Payer: University Health Alliance Commercial	$106.77

38505 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary)

Professional

Both

$2,299.00

Service Code	HCPCS 38505
Hospital Charge Code	8039059
Hospital Revenue Code	975
Min. Negotiated Rate	$74.81
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$85.75
Rate for Payer: AlohaCare Medicare	$74.81
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Devoted Health Medicare	$82.29
Rate for Payer: Hawaii Medical Service Association ABD	$85.75
Rate for Payer: Hawaii Medical Service Association Commercial	$140.72
Rate for Payer: Hawaii Medical Service Association Medicare	$74.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.75
Rate for Payer: Hawaii Western Management Group Commercial	$105.30
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Kaiser Permanente Commercial	$82.29
Rate for Payer: Kaiser Permanente Medicaid	$82.29
Rate for Payer: Kaiser Permanente Medicare	$82.29
Rate for Payer: Ohana Health Plan Medicaid	$85.75
Rate for Payer: Ohana Health Plan Medicare	$74.81
Rate for Payer: UnitedHealthcare Medicaid	$85.75
Rate for Payer: UnitedHealthcare Medicare	$74.81
Rate for Payer: University Health Alliance Commercial	$106.77

38505 CT Biopsy Lymph Node

Facility

$3,181.00

Service Code	HCPCS 38505
Hospital Charge Code	9882955
Hospital Revenue Code	320
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$3,085.57
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: Cash Price	$2,067.65
Rate for Payer: Devoted Health Medicare	$1,749.55
Rate for Payer: Hawaii Medical Service Association Commercial	$2,109.21
Rate for Payer: Hawaii Medical Service Association Medicare	$1,590.50
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,590.50
Rate for Payer: University Health Alliance Commercial	$2,318.63

38505 CT Biopsy Lymph Node

Facility

$3,181.00

Service Code	HCPCS 38505
Hospital Charge Code	9882955
Hospital Revenue Code	320
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

38505 US Biopsy Lymph Node Superficial

Facility

$3,181.00

Service Code	HCPCS 38505
Hospital Charge Code	9887434
Hospital Revenue Code	402
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

38505 US Biopsy Lymph Node Superficial

Facility

$3,181.00

Service Code	HCPCS 38505
Hospital Charge Code	9887434
Hospital Revenue Code	402
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$3,085.57
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: Cash Price	$2,067.65
Rate for Payer: Devoted Health Medicare	$1,749.55
Rate for Payer: Hawaii Medical Service Association Commercial	$2,109.21
Rate for Payer: Hawaii Medical Service Association Medicare	$1,590.50
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	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,590.50
Rate for Payer: University Health Alliance Commercial	$2,318.63

38525 Biopsy or excision of lymph node(s); open, deep axillary node(s)

Professional

Both

$5,449.00

Service Code	HCPCS 38525
Hospital Charge Code	8039062
Hospital Revenue Code	975
Min. Negotiated Rate	$286.78
Max. Negotiated Rate	$4,631.65
Rate for Payer: AlohaCare Medicaid	$446.82
Rate for Payer: AlohaCare Medicare	$430.82
Rate for Payer: Cash Price	$3,541.85
Rate for Payer: Cash Price	$3,541.85
Rate for Payer: Devoted Health Medicare	$473.90
Rate for Payer: Hawaii Medical Service Association Medicare	$430.82
Rate for Payer: Hawaii Western Management Group Commercial	$286.78
Rate for Payer: Health Management Network Commercial	$4,631.65
Rate for Payer: Kaiser Permanente Commercial	$473.90
Rate for Payer: Kaiser Permanente Medicaid	$473.90
Rate for Payer: Kaiser Permanente Medicare	$473.90
Rate for Payer: Ohana Health Plan Medicaid	$446.82
Rate for Payer: Ohana Health Plan Medicare	$430.82
Rate for Payer: UnitedHealthcare Medicaid	$446.82
Rate for Payer: UnitedHealthcare Medicare	$430.82

38900 INTRAOPERATIVE IDENTIFICATION (EG, MAPPING) OF SENTINEL LYMPH NODE(S) INCLUDES INJECTI ProFee

Professional

Both

$344.00

Service Code	HCPCS 38900
Hospital Charge Code	8019525
Hospital Revenue Code	960
Min. Negotiated Rate	$117.59
Max. Negotiated Rate	$292.40
Rate for Payer: AlohaCare Medicaid	$132.48
Rate for Payer: AlohaCare Medicare	$117.59
Rate for Payer: Cash Price	$223.60
Rate for Payer: Cash Price	$223.60
Rate for Payer: Devoted Health Medicare	$129.35
Rate for Payer: Hawaii Medical Service Association Medicare	$117.59
Rate for Payer: Hawaii Western Management Group Commercial	$128.44
Rate for Payer: Health Management Network Commercial	$292.40
Rate for Payer: Kaiser Permanente Commercial	$129.35
Rate for Payer: Kaiser Permanente Medicaid	$129.35
Rate for Payer: Kaiser Permanente Medicare	$129.35
Rate for Payer: Ohana Health Plan Medicaid	$132.48
Rate for Payer: Ohana Health Plan Medicare	$117.59
Rate for Payer: UnitedHealthcare Medicaid	$132.48
Rate for Payer: UnitedHealthcare Medicare	$117.59

3 LEAD SET GRABBER

Facility

$208.00

Hospital Charge Code	8939169
Hospital Revenue Code	272
Min. Negotiated Rate	$104.00
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$104.00
Rate for Payer: Cash Price	$135.20
Rate for Payer: Devoted Health Medicare	$114.40
Rate for Payer: Hawaii Medical Service Association Medicare	$104.00
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$104.00
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$104.00
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$104.00
Rate for Payer: Ohana Health Plan Medicare	$104.00
Rate for Payer: UnitedHealthcare Medicare	$104.00
Rate for Payer: University Health Alliance Commercial	$151.61

3 LEAD SET GRABBER

Facility

$208.00

Hospital Charge Code	8939169
Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

40650-Lip Full Thickness Vermilion Only

Facility

$2,826.00

Service Code	HCPCS 40650
Hospital Charge Code	8080037
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,741.22
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,413.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Devoted Health Medicare	$1,554.30
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	$1,413.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,684.70
Rate for Payer: Health Management Network Commercial	$2,402.10
Rate for Payer: Humana Medicare	$1,413.00
Rate for Payer: Kaiser Permanente Commercial	$2,543.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,413.00
Rate for Payer: MDX Hawaii PPO	$2,741.22
Rate for Payer: Ohana Health Plan Medicaid	$1,413.00
Rate for Payer: Ohana Health Plan Medicare	$1,413.00
Rate for Payer: UnitedHealthcare Medicare	$1,413.00
Rate for Payer: University Health Alliance Commercial	$2,059.87

40650-Lip Full Thickness Vermilion Only

Facility

$2,826.00

Service Code	HCPCS 40650
Hospital Charge Code	8080037
Hospital Revenue Code	450
Min. Negotiated Rate	$2,402.10
Max. Negotiated Rate	$2,741.22
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Health Management Network Commercial	$2,402.10
Rate for Payer: Kaiser Permanente Commercial	$2,543.40
Rate for Payer: MDX Hawaii PPO	$2,741.22

40800 DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL TechFee

Facility

$1,620.00

Service Code	HCPCS 40800
Hospital Charge Code	8211315
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$810.00
Rate for Payer: Cash Price	$1,053.00
Rate for Payer: Cash Price	$1,053.00
Rate for Payer: Cash Price	$1,053.00
Rate for Payer: Devoted Health Medicare	$891.00
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	$810.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,539.00
Rate for Payer: Health Management Network Commercial	$1,377.00
Rate for Payer: Humana Medicare	$810.00
Rate for Payer: Kaiser Permanente Commercial	$1,458.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$810.00
Rate for Payer: MDX Hawaii PPO	$1,571.40
Rate for Payer: Ohana Health Plan Medicaid	$810.00
Rate for Payer: Ohana Health Plan Medicare	$810.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$810.00
Rate for Payer: University Health Alliance Commercial	$1,180.82

40800 DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL TechFee

Facility

$1,620.00

Service Code	HCPCS 40800
Hospital Charge Code	8211315
Hospital Revenue Code	450
Min. Negotiated Rate	$1,377.00
Max. Negotiated Rate	$1,571.40
Rate for Payer: Cash Price	$1,053.00
Rate for Payer: Health Management Network Commercial	$1,377.00
Rate for Payer: Kaiser Permanente Commercial	$1,458.00
Rate for Payer: MDX Hawaii PPO	$1,571.40

40800-I&D Cyst Mouth Simple

Facility

$1,416.00

Service Code	HCPCS 40800
Hospital Charge Code	8080042
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$708.00
Rate for Payer: Cash Price	$920.40
Rate for Payer: Cash Price	$920.40
Rate for Payer: Cash Price	$920.40
Rate for Payer: Devoted Health Medicare	$778.80
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	$708.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,345.20
Rate for Payer: Health Management Network Commercial	$1,203.60
Rate for Payer: Humana Medicare	$708.00
Rate for Payer: Kaiser Permanente Commercial	$1,274.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$708.00
Rate for Payer: MDX Hawaii PPO	$1,373.52
Rate for Payer: Ohana Health Plan Medicaid	$708.00
Rate for Payer: Ohana Health Plan Medicare	$708.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$708.00
Rate for Payer: University Health Alliance Commercial	$1,032.12

40800-I&D Cyst Mouth Simple

Facility

$1,416.00

Service Code	HCPCS 40800
Hospital Charge Code	8080042
Hospital Revenue Code	450
Min. Negotiated Rate	$1,203.60
Max. Negotiated Rate	$1,373.52
Rate for Payer: Cash Price	$920.40
Rate for Payer: Health Management Network Commercial	$1,203.60
Rate for Payer: Kaiser Permanente Commercial	$1,274.40
Rate for Payer: MDX Hawaii PPO	$1,373.52

40801-I&D Cyst Mouth Complicated

Facility

$2,772.00

Service Code	HCPCS 40801
Hospital Charge Code	8080044
Hospital Revenue Code	450
Min. Negotiated Rate	$2,356.20
Max. Negotiated Rate	$2,688.84
Rate for Payer: Cash Price	$1,801.80
Rate for Payer: Health Management Network Commercial	$2,356.20
Rate for Payer: Kaiser Permanente Commercial	$2,494.80
Rate for Payer: MDX Hawaii PPO	$2,688.84

40801-I&D Cyst Mouth Complicated

Facility

$2,772.00

Service Code	HCPCS 40801
Hospital Charge Code	8080044
Hospital Revenue Code	450
Min. Negotiated Rate	$695.00
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$901.48
Rate for Payer: AlohaCare Medicare	$1,386.00
Rate for Payer: Cash Price	$1,801.80
Rate for Payer: Cash Price	$1,801.80
Rate for Payer: Devoted Health Medicare	$1,524.60
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	$1,386.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$2,633.40
Rate for Payer: Health Management Network Commercial	$2,356.20
Rate for Payer: Humana Medicare	$1,386.00
Rate for Payer: Kaiser Permanente Commercial	$2,494.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,386.00
Rate for Payer: MDX Hawaii PPO	$2,688.84
Rate for Payer: Ohana Health Plan Medicaid	$1,386.00
Rate for Payer: Ohana Health Plan Medicare	$1,386.00
Rate for Payer: UnitedHealthcare Medicare	$1,386.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

40830 Repair Mouth Laceration TechFee

Facility

$1,652.00

Service Code	HCPCS 40830
Hospital Charge Code	8343977
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$2,389.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$826.00
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Devoted Health Medicare	$908.60
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	$826.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,569.40
Rate for Payer: Health Management Network Commercial	$1,404.20
Rate for Payer: Humana Medicare	$826.00
Rate for Payer: Kaiser Permanente Commercial	$1,486.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$826.00
Rate for Payer: MDX Hawaii PPO	$1,602.44
Rate for Payer: Ohana Health Plan Medicaid	$826.00
Rate for Payer: Ohana Health Plan Medicare	$826.00
Rate for Payer: UnitedHealthcare Medicare	$826.00
Rate for Payer: University Health Alliance Commercial	$1,204.14

40830 Repair Mouth Laceration TechFee

Facility

$1,652.00

Service Code	HCPCS 40830
Hospital Charge Code	8343977
Hospital Revenue Code	450
Min. Negotiated Rate	$1,404.20
Max. Negotiated Rate	$1,602.44
Rate for Payer: Cash Price	$1,073.80
Rate for Payer: Health Management Network Commercial	$1,404.20
Rate for Payer: Kaiser Permanente Commercial	$1,486.80
Rate for Payer: MDX Hawaii PPO	$1,602.44

41115 Excision of lingual frenum (frenectomy)

Professional

Both

$2,159.00

Service Code	HCPCS 41115
Hospital Charge Code	8039135
Hospital Revenue Code	975
Min. Negotiated Rate	$108.94
Max. Negotiated Rate	$1,835.15
Rate for Payer: AlohaCare Medicaid	$155.28
Rate for Payer: AlohaCare Medicare	$138.86
Rate for Payer: Cash Price	$1,403.35
Rate for Payer: Cash Price	$1,403.35
Rate for Payer: Devoted Health Medicare	$152.75
Rate for Payer: Hawaii Medical Service Association ABD	$155.28
Rate for Payer: Hawaii Medical Service Association Commercial	$256.38
Rate for Payer: Hawaii Medical Service Association Medicare	$138.86
Rate for Payer: Hawaii Medical Service Association Non-ABD	$155.28
Rate for Payer: Hawaii Western Management Group Commercial	$108.94
Rate for Payer: Health Management Network Commercial	$1,835.15
Rate for Payer: Kaiser Permanente Commercial	$152.75
Rate for Payer: Kaiser Permanente Medicaid	$152.75
Rate for Payer: Kaiser Permanente Medicare	$152.75
Rate for Payer: Ohana Health Plan Medicaid	$155.28
Rate for Payer: Ohana Health Plan Medicare	$138.86
Rate for Payer: UnitedHealthcare Medicaid	$155.28
Rate for Payer: UnitedHealthcare Medicare	$138.86
Rate for Payer: University Health Alliance Commercial	$201.92

41250-Mouth Floor/Tongue Ant 2/3 Less Than/Equal to 2.5cm

Facility

$809.00

Service Code	HCPCS 41250
Hospital Charge Code	8080039
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

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