Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$520.00
Max. Negotiated Rate	$2,442.46
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$1,259.00
Rate for Payer: Cash Price	$1,636.70
Rate for Payer: Cash Price	$1,636.70
Rate for Payer: Cash Price	$1,636.70
Rate for Payer: Devoted Health Medicare	$1,384.90
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	$1,259.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,392.10
Rate for Payer: Health Management Network Commercial	$2,140.30
Rate for Payer: Humana Medicare	$1,259.00
Rate for Payer: Kaiser Permanente Commercial	$2,266.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,259.00
Rate for Payer: MDX Hawaii PPO	$2,442.46
Rate for Payer: Ohana Health Plan Medicaid	$1,259.00
Rate for Payer: Ohana Health Plan Medicare	$1,259.00
Rate for Payer: UnitedHealthcare Medicare	$1,259.00
Rate for Payer: University Health Alliance Commercial	$1,835.37

12017-Face/Ear/Eyelid/Nose/Lip 20.1-30.0 cm

Facility

$1,984.00

Service Code	HCPCS 12017
Hospital Charge Code	8080001
Hospital Revenue Code	450
Min. Negotiated Rate	$1,686.40
Max. Negotiated Rate	$1,924.48
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Kaiser Permanente Commercial	$1,785.60
Rate for Payer: MDX Hawaii PPO	$1,924.48

12017-Face/Ear/Eyelid/Nose/Lip 20.1-30.0 cm

Facility

$1,984.00

Service Code	HCPCS 12017
Hospital Charge Code	8080001
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,924.48
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$992.00
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Cash Price	$1,289.60
Rate for Payer: Devoted Health Medicare	$1,091.20
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	$992.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,884.80
Rate for Payer: Health Management Network Commercial	$1,686.40
Rate for Payer: Humana Medicare	$992.00
Rate for Payer: Kaiser Permanente Commercial	$1,785.60
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$992.00
Rate for Payer: MDX Hawaii PPO	$1,924.48
Rate for Payer: Ohana Health Plan Medicaid	$992.00
Rate for Payer: Ohana Health Plan Medicare	$992.00
Rate for Payer: UnitedHealthcare Medicare	$992.00
Rate for Payer: University Health Alliance Commercial	$1,446.14

12018-Face/Ear/Eyelid/Nose/Lip Greater Than 30.0 cm

Facility

$1,133.00

Service Code	HCPCS 12018
Hospital Charge Code	8080003
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

12018-Face/Ear/Eyelid/Nose/Lip Greater Than 30.0 cm

Facility

$1,133.00

Service Code	HCPCS 12018
Hospital Charge Code	8080003
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

12020-Treatment Superficial Wound Dehiscence

Facility

$3,227.00

Service Code	HCPCS 12020
Hospital Charge Code	8080005
Hospital Revenue Code	450
Min. Negotiated Rate	$2,742.95
Max. Negotiated Rate	$3,130.19
Rate for Payer: Cash Price	$2,097.55
Rate for Payer: Health Management Network Commercial	$2,742.95
Rate for Payer: Kaiser Permanente Commercial	$2,904.30
Rate for Payer: MDX Hawaii PPO	$3,130.19

12020-Treatment Superficial Wound Dehiscence

Facility

$3,227.00

Service Code	HCPCS 12020
Hospital Charge Code	8080005
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$3,130.19
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	$2,352.16

12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< TechFee

Facility

$880.00

Service Code	HCPCS 12031
Hospital Charge Code	8022639
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$1,600.00
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	$641.43

12031 REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< TechFee

Facility

$880.00

Service Code	HCPCS 12031
Hospital Charge Code	8022639
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

12031 Repair, intermediate; wounds of scalp, axillae, trunk, extremities; <2.5cm

Professional

Both

$744.00

Service Code	HCPCS 12031
Hospital Charge Code	8037191
Hospital Revenue Code	975
Min. Negotiated Rate	$117.26
Max. Negotiated Rate	$632.40
Rate for Payer: AlohaCare Medicaid	$158.83
Rate for Payer: AlohaCare Medicare	$138.32
Rate for Payer: Cash Price	$483.60
Rate for Payer: Cash Price	$483.60
Rate for Payer: Devoted Health Medicare	$152.15
Rate for Payer: Hawaii Medical Service Association ABD	$158.83
Rate for Payer: Hawaii Medical Service Association Commercial	$260.55
Rate for Payer: Hawaii Medical Service Association Medicare	$138.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$158.83
Rate for Payer: Hawaii Western Management Group Commercial	$117.26
Rate for Payer: Health Management Network Commercial	$632.40
Rate for Payer: Kaiser Permanente Commercial	$152.15
Rate for Payer: Kaiser Permanente Medicaid	$152.15
Rate for Payer: Kaiser Permanente Medicare	$152.15
Rate for Payer: Ohana Health Plan Medicaid	$158.83
Rate for Payer: Ohana Health Plan Medicare	$138.32
Rate for Payer: UnitedHealthcare Medicaid	$158.83
Rate for Payer: UnitedHealthcare Medicare	$138.32
Rate for Payer: University Health Alliance Commercial	$172.77

12031-Scalp/Trunk/Extremity Less Than/Equal to 2.5 cm

Facility

$810.00

Service Code	HCPCS 12031
Hospital Charge Code	8080006
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

12031-Scalp/Trunk/Extremity Less Than/Equal to 2.5 cm

Facility

$810.00

Service Code	HCPCS 12031
Hospital Charge Code	8080006
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$1,600.00
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	$590.41

12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM TechFee

Facility

$880.00

Service Code	HCPCS 12032
Hospital Charge Code	8022640
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

12032 REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM TechFee

Facility

$880.00

Service Code	HCPCS 12032
Hospital Charge Code	8022640
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

12032 Repair, intermediate; wounds of scalp, axillae, trunk, extremities; 2.6-7.5cm

Professional

Both

$943.00

Service Code	HCPCS 12032
Hospital Charge Code	8037192
Hospital Revenue Code	975
Min. Negotiated Rate	$144.30
Max. Negotiated Rate	$801.55
Rate for Payer: AlohaCare Medicaid	$199.83
Rate for Payer: AlohaCare Medicare	$171.50
Rate for Payer: Cash Price	$612.95
Rate for Payer: Cash Price	$612.95
Rate for Payer: Devoted Health Medicare	$188.65
Rate for Payer: Hawaii Medical Service Association ABD	$199.83
Rate for Payer: Hawaii Medical Service Association Commercial	$326.33
Rate for Payer: Hawaii Medical Service Association Medicare	$171.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$199.83
Rate for Payer: Hawaii Western Management Group Commercial	$144.30
Rate for Payer: Health Management Network Commercial	$801.55
Rate for Payer: Kaiser Permanente Commercial	$188.65
Rate for Payer: Kaiser Permanente Medicaid	$188.65
Rate for Payer: Kaiser Permanente Medicare	$188.65
Rate for Payer: Ohana Health Plan Medicaid	$199.83
Rate for Payer: Ohana Health Plan Medicare	$171.50
Rate for Payer: UnitedHealthcare Medicaid	$199.83
Rate for Payer: UnitedHealthcare Medicare	$171.50
Rate for Payer: University Health Alliance Commercial	$217.60

12032-Scalp/Trunk/Extremity 2.6-7.5cm

Facility

$810.00

Service Code	HCPCS 12032
Hospital Charge Code	8080008
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

12032-Scalp/Trunk/Extremity 2.6-7.5cm

Facility

$810.00

Service Code	HCPCS 12032
Hospital Charge Code	8080008
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

12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM TechFee

Facility

$843.00

Service Code	HCPCS 12034
Hospital Charge Code	8022641
Hospital Revenue Code	450
Min. Negotiated Rate	$716.55
Max. Negotiated Rate	$817.71
Rate for Payer: Cash Price	$547.95
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Kaiser Permanente Commercial	$758.70
Rate for Payer: MDX Hawaii PPO	$817.71

12034 REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM TechFee

Facility

$843.00

Service Code	HCPCS 12034
Hospital Charge Code	8022641
Hospital Revenue Code	450
Min. Negotiated Rate	$421.50
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$421.50
Rate for Payer: Cash Price	$547.95
Rate for Payer: Cash Price	$547.95
Rate for Payer: Cash Price	$547.95
Rate for Payer: Devoted Health Medicare	$463.65
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	$421.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$800.85
Rate for Payer: Health Management Network Commercial	$716.55
Rate for Payer: Humana Medicare	$421.50
Rate for Payer: Kaiser Permanente Commercial	$758.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$421.50
Rate for Payer: MDX Hawaii PPO	$817.71
Rate for Payer: Ohana Health Plan Medicaid	$421.50
Rate for Payer: Ohana Health Plan Medicare	$421.50
Rate for Payer: UnitedHealthcare Medicare	$421.50
Rate for Payer: University Health Alliance Commercial	$5,160.40

12034-Scalp/Trunk/Extremity 7.6-12.5 cm

Facility

$868.00

Service Code	HCPCS 12034
Hospital Charge Code	8080010
Hospital Revenue Code	450
Min. Negotiated Rate	$737.80
Max. Negotiated Rate	$841.96
Rate for Payer: Cash Price	$564.20
Rate for Payer: Health Management Network Commercial	$737.80
Rate for Payer: Kaiser Permanente Commercial	$781.20
Rate for Payer: MDX Hawaii PPO	$841.96

12034-Scalp/Trunk/Extremity 7.6-12.5 cm

Facility

$868.00

Service Code	HCPCS 12034
Hospital Charge Code	8080010
Hospital Revenue Code	450
Min. Negotiated Rate	$434.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$434.00
Rate for Payer: Cash Price	$564.20
Rate for Payer: Cash Price	$564.20
Rate for Payer: Cash Price	$564.20
Rate for Payer: Devoted Health Medicare	$477.40
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	$434.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$824.60
Rate for Payer: Health Management Network Commercial	$737.80
Rate for Payer: Humana Medicare	$434.00
Rate for Payer: Kaiser Permanente Commercial	$781.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$434.00
Rate for Payer: MDX Hawaii PPO	$841.96
Rate for Payer: Ohana Health Plan Medicaid	$434.00
Rate for Payer: Ohana Health Plan Medicare	$434.00
Rate for Payer: UnitedHealthcare Medicare	$434.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

12035 REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM TechFee

Facility

$880.00

Service Code	HCPCS 12035
Hospital Charge Code	8022642
Hospital Revenue Code	450
Min. Negotiated Rate	$440.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: Ohana Health Plan Medicaid	$440.00
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 Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$5,160.40

12035 REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM TechFee

Facility

$880.00

Service Code	HCPCS 12035
Hospital Charge Code	8022642
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

12035-Scalp/Trunk/Extremity 12.6-20.0 cm

Facility

$810.00

Service Code	HCPCS 12035
Hospital Charge Code	8080012
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

12035-Scalp/Trunk/Extremity 12.6-20.0 cm

Facility

$810.00

Service Code	HCPCS 12035
Hospital Charge Code	8080012
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

Know your out-of-pocket cost for care.

All Charges