Kona Community Hospital

All Charges

Charge

Type

Setting

Price

DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYR

Facility

$2,511.60

Service Code	HCPCS J0881
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$2,436.25
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$1,632.54
Rate for Payer: Cash Price	$1,632.54
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,386.02
Rate for Payer: Health Management Network Commercial	$2,134.86
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$1,582.31
Rate for Payer: Kaiser Permanente Medicaid	$1,280.92
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$2,436.25
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$1,506.96
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$1,830.71

DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYR

Facility

$2,511.60

Service Code	HCPCS J0881
Hospital Revenue Code	250
Min. Negotiated Rate	$2,134.86
Max. Negotiated Rate	$2,436.25
Rate for Payer: Cash Price	$1,632.54
Rate for Payer: Health Management Network Commercial	$2,134.86
Rate for Payer: MDX Hawaii PPO	$2,436.25

DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYR FOR ESRD

Facility

$2,511.60

Service Code	HCPCS J0882
Hospital Revenue Code	250
Min. Negotiated Rate	$2,134.86
Max. Negotiated Rate	$2,436.25
Rate for Payer: Cash Price	$1,632.54
Rate for Payer: Health Management Network Commercial	$2,134.86
Rate for Payer: MDX Hawaii PPO	$2,436.25

DARBEPOETIN ALFA IN POLYSORBAT 150 MCG/0.3 ML INJ SYR FOR ESRD

Facility

$2,511.60

Service Code	HCPCS J0882
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$2,436.25
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$1,632.54
Rate for Payer: Cash Price	$1,632.54
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,386.02
Rate for Payer: Health Management Network Commercial	$2,134.86
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$1,582.31
Rate for Payer: Kaiser Permanente Medicaid	$1,280.92
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$2,436.25
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$1,506.96
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$1,830.71

DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYR

Facility

$2,976.00

Service Code	HCPCS J0881
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$2,886.72
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$1,934.40
Rate for Payer: Cash Price	$1,934.40
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,827.20
Rate for Payer: Health Management Network Commercial	$2,529.60
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$1,874.88
Rate for Payer: Kaiser Permanente Medicaid	$1,517.76
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$2,886.72
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$1,785.60
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$2,169.21

DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYR

Facility

$2,976.00

Service Code	HCPCS J0881
Hospital Revenue Code	250
Min. Negotiated Rate	$2,529.60
Max. Negotiated Rate	$2,886.72
Rate for Payer: Cash Price	$1,934.40
Rate for Payer: Health Management Network Commercial	$2,529.60
Rate for Payer: MDX Hawaii PPO	$2,886.72

DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYR

Facility

$3,904.80

Service Code	HCPCS J0881
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3,787.66
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$2,538.12
Rate for Payer: Cash Price	$2,538.12
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,709.56
Rate for Payer: Health Management Network Commercial	$3,319.08
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$2,460.02
Rate for Payer: Kaiser Permanente Medicaid	$1,991.45
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$3,787.66
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$2,342.88
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$2,846.21

DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYR

Facility

$3,904.80

Service Code	HCPCS J0881
Hospital Revenue Code	250
Min. Negotiated Rate	$3,319.08
Max. Negotiated Rate	$3,787.66
Rate for Payer: Cash Price	$2,538.12
Rate for Payer: Health Management Network Commercial	$3,319.08
Rate for Payer: MDX Hawaii PPO	$3,787.66

DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYR FOR ESRD

Facility

$3,904.80

Service Code	HCPCS J0882
Hospital Revenue Code	250
Min. Negotiated Rate	$3,319.08
Max. Negotiated Rate	$3,787.66
Rate for Payer: Cash Price	$2,538.12
Rate for Payer: Health Management Network Commercial	$3,319.08
Rate for Payer: MDX Hawaii PPO	$3,787.66

DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYR FOR ESRD

Facility

$3,904.80

Service Code	HCPCS J0882
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3,787.66
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$2,538.12
Rate for Payer: Cash Price	$2,538.12
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,709.56
Rate for Payer: Health Management Network Commercial	$3,319.08
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$2,460.02
Rate for Payer: Kaiser Permanente Medicaid	$1,991.45
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$3,787.66
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$2,342.88
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$2,846.21

DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYR

Facility

$882.73

Service Code	HCPCS J0881
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$856.25
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$573.77
Rate for Payer: Cash Price	$573.77
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$838.59
Rate for Payer: Health Management Network Commercial	$750.32
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$556.12
Rate for Payer: Kaiser Permanente Medicaid	$450.19
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$856.25
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$529.64
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$643.42

DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYR

Facility

$882.73

Service Code	HCPCS J0881
Hospital Revenue Code	250
Min. Negotiated Rate	$750.32
Max. Negotiated Rate	$856.25
Rate for Payer: Cash Price	$573.77
Rate for Payer: Health Management Network Commercial	$750.32
Rate for Payer: MDX Hawaii PPO	$856.25

DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYR FOR ESRD

Facility

$882.73

Service Code	HCPCS J0882
Hospital Revenue Code	250
Min. Negotiated Rate	$750.32
Max. Negotiated Rate	$856.25
Rate for Payer: Cash Price	$573.77
Rate for Payer: Health Management Network Commercial	$750.32
Rate for Payer: MDX Hawaii PPO	$856.25

DARBEPOETIN ALFA IN POLYSORBAT 40 MCG/0.4 ML INJ SYR FOR ESRD

Facility

$882.73

Service Code	HCPCS J0882
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$856.25
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$573.77
Rate for Payer: Cash Price	$573.77
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$838.59
Rate for Payer: Health Management Network Commercial	$750.32
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$556.12
Rate for Payer: Kaiser Permanente Medicaid	$450.19
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$856.25
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$529.64
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$643.42

DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYR

Facility

$1,204.10

Service Code	HCPCS J0881
Hospital Revenue Code	250
Min. Negotiated Rate	$1,023.49
Max. Negotiated Rate	$1,167.98
Rate for Payer: Cash Price	$782.66
Rate for Payer: Health Management Network Commercial	$1,023.49
Rate for Payer: MDX Hawaii PPO	$1,167.98

DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYR

Facility

$1,204.10

Service Code	HCPCS J0881
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$1,167.98
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$782.66
Rate for Payer: Cash Price	$782.66
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,143.89
Rate for Payer: Health Management Network Commercial	$1,023.49
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$758.58
Rate for Payer: Kaiser Permanente Medicaid	$614.09
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$1,167.98
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$722.46
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$877.67

DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYR FOR ESRD

Facility

$1,204.10

Service Code	HCPCS J0882
Hospital Revenue Code	250
Min. Negotiated Rate	$1,023.49
Max. Negotiated Rate	$1,167.98
Rate for Payer: Cash Price	$782.66
Rate for Payer: Health Management Network Commercial	$1,023.49
Rate for Payer: MDX Hawaii PPO	$1,167.98

DARBEPOETIN ALFA IN POLYSORBAT 60 MCG/0.3 ML INJ SYR FOR ESRD

Facility

$1,204.10

Service Code	HCPCS J0882
Hospital Revenue Code	636
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$1,167.98
Rate for Payer: AlohaCare Medicaid	$3.07
Rate for Payer: AlohaCare Medicare	$3.07
Rate for Payer: Cash Price	$782.66
Rate for Payer: Cash Price	$782.66
Rate for Payer: Devoted Health Medicare	$3.38
Rate for Payer: Hawaii Medical Service Association ABD	$3.00
Rate for Payer: Hawaii Medical Service Association Commercial	$3.84
Rate for Payer: Hawaii Medical Service Association Medicare	$3.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,143.89
Rate for Payer: Health Management Network Commercial	$1,023.49
Rate for Payer: Humana Medicare	$3.07
Rate for Payer: Kaiser Permanente Commercial	$758.58
Rate for Payer: Kaiser Permanente Medicaid	$614.09
Rate for Payer: Kaiser Permanente Medicare	$3.07
Rate for Payer: MDX Hawaii PPO	$1,167.98
Rate for Payer: Ohana Health Plan Medicaid	$3.38
Rate for Payer: Ohana Health Plan Medicare	$3.07
Rate for Payer: UnitedHealthcare Medicaid	$722.46
Rate for Payer: UnitedHealthcare Medicare	$3.07
Rate for Payer: University Health Alliance Commercial	$877.67

DARUNAVIR 800 MG PO TABLET

Facility

$68.93

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$35.15
Max. Negotiated Rate	$66.86
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cash Price	$234.19
Rate for Payer: Hawaii Western Management Group Commercial	$342.28
Rate for Payer: Hawaii Western Management Group Commercial	$65.48
Rate for Payer: Health Management Network Commercial	$306.25
Rate for Payer: Health Management Network Commercial	$58.59
Rate for Payer: Kaiser Permanente Commercial	$43.43
Rate for Payer: Kaiser Permanente Commercial	$226.98
Rate for Payer: Kaiser Permanente Medicaid	$35.15
Rate for Payer: Kaiser Permanente Medicaid	$183.75
Rate for Payer: MDX Hawaii PPO	$349.48
Rate for Payer: MDX Hawaii PPO	$66.86
Rate for Payer: UnitedHealthcare Medicaid	$216.17
Rate for Payer: UnitedHealthcare Medicaid	$41.36
Rate for Payer: University Health Alliance Commercial	$50.24
Rate for Payer: University Health Alliance Commercial	$262.62

DARUNAVIR 800 MG PO TABLET

Facility

$360.29

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$306.25
Max. Negotiated Rate	$349.48
Rate for Payer: Cash Price	$234.19
Rate for Payer: Cash Price	$44.80
Rate for Payer: Health Management Network Commercial	$306.25
Rate for Payer: Health Management Network Commercial	$58.59
Rate for Payer: MDX Hawaii PPO	$349.48
Rate for Payer: MDX Hawaii PPO	$66.86

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC

Facility

$35,346.97

Service Code	MSDRG 744
Min. Negotiated Rate	$15,910.62
Max. Negotiated Rate	$35,346.97
Rate for Payer: AlohaCare Medicare	$26,951.33
Rate for Payer: Devoted Health Medicare	$29,646.46
Rate for Payer: Hawaii Medical Service Association Commercial	$15,910.62
Rate for Payer: Hawaii Medical Service Association Medicare	$26,951.33
Rate for Payer: Humana Medicare	$26,951.33
Rate for Payer: Kaiser Permanente Commercial	$35,346.97
Rate for Payer: Kaiser Permanente Medicare	$26,951.33
Rate for Payer: Ohana Health Plan Medicare	$26,951.33
Rate for Payer: UnitedHealthcare Medicare	$26,951.33

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$19,621.88

Service Code	MSDRG 745
Min. Negotiated Rate	$14,961.28
Max. Negotiated Rate	$19,621.88
Rate for Payer: AlohaCare Medicare	$14,961.28
Rate for Payer: Devoted Health Medicare	$16,457.41
Rate for Payer: Hawaii Medical Service Association Commercial	$15,910.62
Rate for Payer: Hawaii Medical Service Association Medicare	$14,961.28
Rate for Payer: Humana Medicare	$14,961.28
Rate for Payer: Kaiser Permanente Commercial	$19,621.88
Rate for Payer: Kaiser Permanente Medicare	$14,961.28
Rate for Payer: Ohana Health Plan Medicare	$14,961.28
Rate for Payer: UnitedHealthcare Medicare	$14,961.28

DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$9,416.00

Service Code	CPT 11044
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$1,951.11
Rate for Payer: AlohaCare Medicare	$1,951.11
Rate for Payer: Devoted Health Medicare	$2,146.22
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,951.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$1,951.11
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,951.11
Rate for Payer: Ohana Health Plan Medicaid	$2,146.22
Rate for Payer: Ohana Health Plan Medicare	$1,951.11
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,951.11

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE

Facility

$9,416.00

Service Code	CPT 11011
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Devoted Health Medicare	$920.21
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$836.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL AT THE SITE OF AN OPEN FRACTURE AND/OR AN OPEN DISLOCATION (EG, EXCISIONAL DEBRIDEMENT); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE

Facility

$6,743.44

Service Code	CPT 11012
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,431.47
Rate for Payer: AlohaCare Medicare	$3,431.47
Rate for Payer: Devoted Health Medicare	$3,774.62
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,431.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$3,431.47
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,431.47
Rate for Payer: Ohana Health Plan Medicaid	$3,774.62
Rate for Payer: Ohana Health Plan Medicare	$3,431.47
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,431.47
Rate for Payer: University Health Alliance Commercial	$6,743.44

Know your out-of-pocket cost for care.

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