Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

12006-Scalp/Neck/Trunk/Genital/Extremity 20.1-30 cm

Facility

$2,175.00

Service Code	HCPCS 12006
Hospital Charge Code	8080000
Hospital Revenue Code	450
Min. Negotiated Rate	$1,848.75
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,413.75
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: Kaiser Permanente Commercial	$1,957.50
Rate for Payer: MDX Hawaii PPO	$2,109.75

12006-Scalp/Neck/Trunk/Genital/Extremity 20.1-30 cm

Facility

$2,175.00

Service Code	HCPCS 12006
Hospital Charge Code	8080000
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,109.75
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,087.50
Rate for Payer: Cash Price	$1,413.75
Rate for Payer: Cash Price	$1,413.75
Rate for Payer: Cash Price	$1,413.75
Rate for Payer: Devoted Health Medicare	$1,196.25
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	$1,087.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,066.25
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: Humana Medicare	$1,087.50
Rate for Payer: Kaiser Permanente Commercial	$1,957.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,087.50
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: Ohana Health Plan Medicaid	$1,087.50
Rate for Payer: Ohana Health Plan Medicare	$1,087.50
Rate for Payer: UnitedHealthcare Medicare	$1,087.50
Rate for Payer: University Health Alliance Commercial	$1,585.36

12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM TechFee

Facility

$2,548.00

Service Code	HCPCS 12006
Hospital Charge Code	8022628
Hospital Revenue Code	450
Min. Negotiated Rate	$2,165.80
Max. Negotiated Rate	$2,471.56
Rate for Payer: Cash Price	$1,656.20
Rate for Payer: Health Management Network Commercial	$2,165.80
Rate for Payer: Kaiser Permanente Commercial	$2,293.20
Rate for Payer: MDX Hawaii PPO	$2,471.56

12006 SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM TechFee

Facility

$2,548.00

Service Code	HCPCS 12006
Hospital Charge Code	8022628
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,471.56
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,274.00
Rate for Payer: Cash Price	$1,656.20
Rate for Payer: Cash Price	$1,656.20
Rate for Payer: Cash Price	$1,656.20
Rate for Payer: Devoted Health Medicare	$1,401.40
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	$1,274.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,420.60
Rate for Payer: Health Management Network Commercial	$2,165.80
Rate for Payer: Humana Medicare	$1,274.00
Rate for Payer: Kaiser Permanente Commercial	$2,293.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,274.00
Rate for Payer: MDX Hawaii PPO	$2,471.56
Rate for Payer: Ohana Health Plan Medicaid	$1,274.00
Rate for Payer: Ohana Health Plan Medicare	$1,274.00
Rate for Payer: UnitedHealthcare Medicare	$1,274.00
Rate for Payer: University Health Alliance Commercial	$1,857.24

12007-Scalp/Neck/Trunk/Genital/Extremity Greater Than 30 cm

Facility

$1,133.00

Service Code	HCPCS 12007
Hospital Charge Code	8080002
Hospital Revenue Code	450
Min. Negotiated Rate	$963.05
Max. Negotiated Rate	$1,099.01
Rate for Payer: Cash Price	$736.45
Rate for Payer: Health Management Network Commercial	$963.05
Rate for Payer: Kaiser Permanente Commercial	$1,019.70
Rate for Payer: MDX Hawaii PPO	$1,099.01

12007-Scalp/Neck/Trunk/Genital/Extremity Greater Than 30 cm

Facility

$1,133.00

Service Code	HCPCS 12007
Hospital Charge Code	8080002
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	$566.50
Rate for Payer: Cash Price	$736.45
Rate for Payer: Cash Price	$736.45
Rate for Payer: Cash Price	$736.45
Rate for Payer: Devoted Health Medicare	$623.15
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$566.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,076.35
Rate for Payer: Health Management Network Commercial	$963.05
Rate for Payer: Humana Medicare	$566.50
Rate for Payer: Kaiser Permanente Commercial	$1,019.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$566.50
Rate for Payer: MDX Hawaii PPO	$1,099.01
Rate for Payer: Ohana Health Plan Medicaid	$566.50
Rate for Payer: Ohana Health Plan Medicare	$566.50
Rate for Payer: UnitedHealthcare Medicare	$566.50
Rate for Payer: University Health Alliance Commercial	$825.84

12011-Face/Ear/Eyelid/Nose/Lip Less Than/Equal to 2.5 cm

Facility

$786.00

Service Code	HCPCS 12011
Hospital Charge Code	8080004
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$393.00
Rate for Payer: Cash Price	$510.90
Rate for Payer: Cash Price	$510.90
Rate for Payer: Cash Price	$510.90
Rate for Payer: Devoted Health Medicare	$432.30
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	$393.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$746.70
Rate for Payer: Health Management Network Commercial	$668.10
Rate for Payer: Humana Medicare	$393.00
Rate for Payer: Kaiser Permanente Commercial	$707.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$393.00
Rate for Payer: MDX Hawaii PPO	$762.42
Rate for Payer: Ohana Health Plan Medicaid	$393.00
Rate for Payer: Ohana Health Plan Medicare	$393.00
Rate for Payer: UnitedHealthcare Medicare	$393.00
Rate for Payer: University Health Alliance Commercial	$572.92

12011-Face/Ear/Eyelid/Nose/Lip Less Than/Equal to 2.5 cm

Facility

$786.00

Service Code	HCPCS 12011
Hospital Charge Code	8080004
Hospital Revenue Code	450
Min. Negotiated Rate	$668.10
Max. Negotiated Rate	$762.42
Rate for Payer: Cash Price	$510.90
Rate for Payer: Health Management Network Commercial	$668.10
Rate for Payer: Kaiser Permanente Commercial	$707.40
Rate for Payer: MDX Hawaii PPO	$762.42

12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< TechFee

Facility

$836.00

Service Code	HCPCS 12011
Hospital Charge Code	8022630
Hospital Revenue Code	450
Min. Negotiated Rate	$418.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$418.00
Rate for Payer: Cash Price	$543.40
Rate for Payer: Cash Price	$543.40
Rate for Payer: Cash Price	$543.40
Rate for Payer: Devoted Health Medicare	$459.80
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	$418.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$794.20
Rate for Payer: Health Management Network Commercial	$710.60
Rate for Payer: Humana Medicare	$418.00
Rate for Payer: Kaiser Permanente Commercial	$752.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$418.00
Rate for Payer: MDX Hawaii PPO	$810.92
Rate for Payer: Ohana Health Plan Medicaid	$418.00
Rate for Payer: Ohana Health Plan Medicare	$418.00
Rate for Payer: UnitedHealthcare Medicare	$418.00
Rate for Payer: University Health Alliance Commercial	$609.36

12011 SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< TechFee

Facility

$836.00

Service Code	HCPCS 12011
Hospital Charge Code	8022630
Hospital Revenue Code	450
Min. Negotiated Rate	$710.60
Max. Negotiated Rate	$810.92
Rate for Payer: Cash Price	$543.40
Rate for Payer: Health Management Network Commercial	$710.60
Rate for Payer: Kaiser Permanente Commercial	$752.40
Rate for Payer: MDX Hawaii PPO	$810.92

12013-Face/Ear/Eyelid/Nose/Lip 2.6-5.0 cm

Facility

$786.00

Service Code	HCPCS 12013
Hospital Charge Code	8079993
Hospital Revenue Code	450
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$393.00
Rate for Payer: Cash Price	$510.90
Rate for Payer: Cash Price	$510.90
Rate for Payer: Cash Price	$510.90
Rate for Payer: Devoted Health Medicare	$432.30
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	$393.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$746.70
Rate for Payer: Health Management Network Commercial	$668.10
Rate for Payer: Humana Medicare	$393.00
Rate for Payer: Kaiser Permanente Commercial	$707.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$393.00
Rate for Payer: MDX Hawaii PPO	$762.42
Rate for Payer: Ohana Health Plan Medicaid	$393.00
Rate for Payer: Ohana Health Plan Medicare	$393.00
Rate for Payer: UnitedHealthcare Medicare	$393.00
Rate for Payer: University Health Alliance Commercial	$572.92

12013-Face/Ear/Eyelid/Nose/Lip 2.6-5.0 cm

Facility

$786.00

Service Code	HCPCS 12013
Hospital Charge Code	8079993
Hospital Revenue Code	450
Min. Negotiated Rate	$668.10
Max. Negotiated Rate	$762.42
Rate for Payer: Cash Price	$510.90
Rate for Payer: Health Management Network Commercial	$668.10
Rate for Payer: Kaiser Permanente Commercial	$707.40
Rate for Payer: MDX Hawaii PPO	$762.42

12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM TechFee

Facility

$836.00

Service Code	HCPCS 12013
Hospital Charge Code	8022631
Hospital Revenue Code	450
Min. Negotiated Rate	$710.60
Max. Negotiated Rate	$810.92
Rate for Payer: Cash Price	$543.40
Rate for Payer: Health Management Network Commercial	$710.60
Rate for Payer: Kaiser Permanente Commercial	$752.40
Rate for Payer: MDX Hawaii PPO	$810.92

12013 SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM TechFee

Facility

$836.00

Service Code	HCPCS 12013
Hospital Charge Code	8022631
Hospital Revenue Code	450
Min. Negotiated Rate	$418.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$418.00
Rate for Payer: Cash Price	$543.40
Rate for Payer: Cash Price	$543.40
Rate for Payer: Cash Price	$543.40
Rate for Payer: Devoted Health Medicare	$459.80
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	$418.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$794.20
Rate for Payer: Health Management Network Commercial	$710.60
Rate for Payer: Humana Medicare	$418.00
Rate for Payer: Kaiser Permanente Commercial	$752.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$418.00
Rate for Payer: MDX Hawaii PPO	$810.92
Rate for Payer: Ohana Health Plan Medicaid	$418.00
Rate for Payer: Ohana Health Plan Medicare	$418.00
Rate for Payer: UnitedHealthcare Medicare	$418.00
Rate for Payer: University Health Alliance Commercial	$609.36

12014-Face/Ear/Eyelid/Nose/Lip 5.1-7.5 cm

Facility

$699.00

Service Code	HCPCS 12014
Hospital Charge Code	8079995
Hospital Revenue Code	450
Min. Negotiated Rate	$349.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
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	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$664.05
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$509.50

12014-Face/Ear/Eyelid/Nose/Lip 5.1-7.5 cm

Facility

$699.00

Service Code	HCPCS 12014
Hospital Charge Code	8079995
Hospital Revenue Code	450
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM TechFee

Facility

$769.00

Service Code	HCPCS 12014
Hospital Charge Code	8022632
Hospital Revenue Code	450
Min. Negotiated Rate	$384.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$384.50
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Devoted Health Medicare	$422.95
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	$384.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Humana Medicare	$384.50
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$384.50
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: Ohana Health Plan Medicaid	$384.50
Rate for Payer: Ohana Health Plan Medicare	$384.50
Rate for Payer: UnitedHealthcare Medicare	$384.50
Rate for Payer: University Health Alliance Commercial	$560.52

12014 SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM TechFee

Facility

$769.00

Service Code	HCPCS 12014
Hospital Charge Code	8022632
Hospital Revenue Code	450
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

12015-Face/Ear/Eyelid/Nose/Lip 7.6-12.5 cm

Facility

$699.00

Service Code	HCPCS 12015
Hospital Charge Code	8079997
Hospital Revenue Code	450
Min. Negotiated Rate	$349.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
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	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$664.05
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$509.50

12015-Face/Ear/Eyelid/Nose/Lip 7.6-12.5 cm

Facility

$699.00

Service Code	HCPCS 12015
Hospital Charge Code	8079997
Hospital Revenue Code	450
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM TechFee

Facility

$769.00

Service Code	HCPCS 12015
Hospital Charge Code	8022633
Hospital Revenue Code	450
Min. Negotiated Rate	$384.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$384.50
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Cash Price	$499.85
Rate for Payer: Devoted Health Medicare	$422.95
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	$384.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$730.55
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Humana Medicare	$384.50
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$384.50
Rate for Payer: MDX Hawaii PPO	$745.93
Rate for Payer: Ohana Health Plan Medicaid	$384.50
Rate for Payer: Ohana Health Plan Medicare	$384.50
Rate for Payer: UnitedHealthcare Medicare	$384.50
Rate for Payer: University Health Alliance Commercial	$560.52

12015 SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM TechFee

Facility

$769.00

Service Code	HCPCS 12015
Hospital Charge Code	8022633
Hospital Revenue Code	450
Min. Negotiated Rate	$653.65
Max. Negotiated Rate	$745.93
Rate for Payer: Cash Price	$499.85
Rate for Payer: Health Management Network Commercial	$653.65
Rate for Payer: Kaiser Permanente Commercial	$692.10
Rate for Payer: MDX Hawaii PPO	$745.93

12016-Face/Ear/Eyelid/Nose/Lip 12.6-20.0 cm

Facility

$2,150.00

Service Code	HCPCS 12016
Hospital Charge Code	8079999
Hospital Revenue Code	450
Min. Negotiated Rate	$1,827.50
Max. Negotiated Rate	$2,085.50
Rate for Payer: Cash Price	$1,397.50
Rate for Payer: Health Management Network Commercial	$1,827.50
Rate for Payer: Kaiser Permanente Commercial	$1,935.00
Rate for Payer: MDX Hawaii PPO	$2,085.50

12016-Face/Ear/Eyelid/Nose/Lip 12.6-20.0 cm

Facility

$2,150.00

Service Code	HCPCS 12016
Hospital Charge Code	8079999
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,085.50
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,075.00
Rate for Payer: Cash Price	$1,397.50
Rate for Payer: Cash Price	$1,397.50
Rate for Payer: Cash Price	$1,397.50
Rate for Payer: Devoted Health Medicare	$1,182.50
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,075.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,042.50
Rate for Payer: Health Management Network Commercial	$1,827.50
Rate for Payer: Humana Medicare	$1,075.00
Rate for Payer: Kaiser Permanente Commercial	$1,935.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,075.00
Rate for Payer: MDX Hawaii PPO	$2,085.50
Rate for Payer: Ohana Health Plan Medicaid	$1,075.00
Rate for Payer: Ohana Health Plan Medicare	$1,075.00
Rate for Payer: UnitedHealthcare Medicare	$1,075.00
Rate for Payer: University Health Alliance Commercial	$1,567.13

12016 SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM TechFee

Facility

$2,518.00

Service Code	HCPCS 12016
Hospital Charge Code	8022634
Hospital Revenue Code	450
Min. Negotiated Rate	$2,140.30
Max. Negotiated Rate	$2,442.46
Rate for Payer: Cash Price	$1,636.70
Rate for Payer: Health Management Network Commercial	$2,140.30
Rate for Payer: Kaiser Permanente Commercial	$2,266.20
Rate for Payer: MDX Hawaii PPO	$2,442.46

Know your out-of-pocket cost for care.

All Charges