|
12054 REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM TechFee
|
Facility
|
OP
|
$880.00
|
|
|
Service Code
|
HCPCS 12054
|
| Hospital Charge Code |
8022654
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$440.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$440.00
|
| Rate for Payer: AlohaCare Medicare |
$440.00
|
| 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 |
$469.00
|
| 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 |
$450.00
|
| 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
|
|
|
12055-Face/Ear/Eye/Nose/Lip 12.6-20.0 cm
|
Facility
|
OP
|
$1,984.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
8080019
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,924.48 |
| Rate for Payer: AlohaCare Medicaid |
$992.00
|
| 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: Devoted Health Medicare |
$1,091.20
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| 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 |
$450.00
|
| 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
|
|
|
12055-Face/Ear/Eye/Nose/Lip 12.6-20.0 cm
|
Facility
|
IP
|
$1,984.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
8080019
|
|
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
|
|
|
12055 Intermed repair of wounds; face, ears, eyelids, nose, lips, mucous membra; 12.6-20.0cm
|
Professional
|
Both
|
$1,251.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
8037206
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$1,063.35 |
| Rate for Payer: AlohaCare Medicaid |
$307.96
|
| Rate for Payer: AlohaCare Medicare |
$298.09
|
| Rate for Payer: Cash Price |
$813.15
|
| Rate for Payer: Cash Price |
$813.15
|
| Rate for Payer: Cash Price |
$813.15
|
| Rate for Payer: Devoted Health Medicare |
$327.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$470.09
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$301.60
|
| Rate for Payer: Health Management Network Commercial |
$1,063.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$357.71
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$307.96
|
| Rate for Payer: Ohana Health Plan Medicare |
$298.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$347.86
|
|
|
12056-Face/Ear/Eye/Nose/Lip 20.1-30.0 cm
|
Facility
|
IP
|
$1,595.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
8080021
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,355.75 |
| Max. Negotiated Rate |
$1,547.15 |
| Rate for Payer: Cash Price |
$1,036.75
|
| Rate for Payer: Health Management Network Commercial |
$1,355.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,435.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,547.15
|
|
|
12056-Face/Ear/Eye/Nose/Lip 20.1-30.0 cm
|
Facility
|
OP
|
$1,595.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
8080021
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$797.50
|
| Rate for Payer: AlohaCare Medicare |
$797.50
|
| Rate for Payer: Cash Price |
$1,036.75
|
| Rate for Payer: Cash Price |
$1,036.75
|
| Rate for Payer: Devoted Health Medicare |
$877.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$797.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,515.25
|
| Rate for Payer: Health Management Network Commercial |
$1,355.75
|
| Rate for Payer: Humana Medicare |
$797.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,435.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$797.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,547.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$797.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$797.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$797.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,162.60
|
|
|
12056 Intermed repair of wounds; face, ears, eyelids, nose, lips, mucous membra; 20.1-30.0cm
|
Professional
|
Both
|
$1,505.00
|
|
|
Service Code
|
HCPCS 12056
|
| Hospital Charge Code |
8037207
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$1,279.25 |
| Rate for Payer: AlohaCare Medicaid |
$395.14
|
| Rate for Payer: AlohaCare Medicare |
$354.93
|
| Rate for Payer: Cash Price |
$978.25
|
| Rate for Payer: Cash Price |
$978.25
|
| Rate for Payer: Cash Price |
$978.25
|
| Rate for Payer: Devoted Health Medicare |
$390.42
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$558.30
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$301.86
|
| Rate for Payer: Health Management Network Commercial |
$1,279.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$425.92
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$395.14
|
| Rate for Payer: Ohana Health Plan Medicare |
$354.93
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$452.68
|
|
|
12057-Face/Ear/Eye/Nose/Lip Greater Than 30.0 cm
|
Facility
|
OP
|
$1,595.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
8080023
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$797.50
|
| Rate for Payer: AlohaCare Medicare |
$797.50
|
| Rate for Payer: Cash Price |
$1,036.75
|
| Rate for Payer: Cash Price |
$1,036.75
|
| Rate for Payer: Devoted Health Medicare |
$877.25
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$797.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,515.25
|
| Rate for Payer: Health Management Network Commercial |
$1,355.75
|
| Rate for Payer: Humana Medicare |
$797.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,435.50
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$797.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,547.15
|
| Rate for Payer: Ohana Health Plan Medicaid |
$797.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$797.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$797.50
|
| Rate for Payer: University Health Alliance Commercial |
$1,162.60
|
|
|
12057-Face/Ear/Eye/Nose/Lip Greater Than 30.0 cm
|
Facility
|
IP
|
$1,595.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
8080023
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,355.75 |
| Max. Negotiated Rate |
$1,547.15 |
| Rate for Payer: Cash Price |
$1,036.75
|
| Rate for Payer: Health Management Network Commercial |
$1,355.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,435.50
|
| Rate for Payer: MDX Hawaii PPO |
$1,547.15
|
|
|
12057 Repair, intermediate, wounds of face/ears/eyelids/nose/lips and/or mucous membranes; > 30.0 cm
|
Professional
|
Both
|
$1,716.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
8037208
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$1,458.60 |
| Rate for Payer: AlohaCare Medicaid |
$429.09
|
| Rate for Payer: AlohaCare Medicare |
$387.75
|
| Rate for Payer: Cash Price |
$1,115.40
|
| Rate for Payer: Cash Price |
$1,115.40
|
| Rate for Payer: Cash Price |
$1,115.40
|
| Rate for Payer: Devoted Health Medicare |
$426.52
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$637.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$336.96
|
| Rate for Payer: Health Management Network Commercial |
$1,458.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$465.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$429.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$387.75
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$491.55
|
|
|
13100 Repair, complex, trunk; 1.1 cm to 2.5 cm
|
Professional
|
Both
|
$1,029.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
8037209
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$166.92 |
| Max. Negotiated Rate |
$874.65 |
| Rate for Payer: AlohaCare Medicaid |
$206.40
|
| Rate for Payer: AlohaCare Medicare |
$174.70
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Devoted Health Medicare |
$192.17
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$317.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$166.92
|
| Rate for Payer: Health Management Network Commercial |
$874.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$206.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$235.23
|
|
|
13100-Trunk 1.1-2.5 cm
|
Facility
|
OP
|
$3,028.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
8080025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$2,937.16 |
| Rate for Payer: AlohaCare Medicaid |
$1,514.00
|
| Rate for Payer: AlohaCare Medicare |
$1,514.00
|
| Rate for Payer: Cash Price |
$1,968.20
|
| Rate for Payer: Cash Price |
$1,968.20
|
| Rate for Payer: Devoted Health Medicare |
$1,665.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,514.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,876.60
|
| Rate for Payer: Health Management Network Commercial |
$2,573.80
|
| Rate for Payer: Humana Medicare |
$1,514.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,725.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,514.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,937.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,514.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,514.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,514.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,207.11
|
|
|
13100-Trunk 1.1-2.5 cm
|
Facility
|
IP
|
$3,028.00
|
|
|
Service Code
|
HCPCS 13100
|
| Hospital Charge Code |
8080025
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,573.80 |
| Max. Negotiated Rate |
$2,937.16 |
| Rate for Payer: Cash Price |
$1,968.20
|
| Rate for Payer: Health Management Network Commercial |
$2,573.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,725.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,937.16
|
|
|
13101 Repair, complex, trunk; 2.6 cm to 7.5 cm
|
Professional
|
Both
|
$1,164.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
8037210
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$989.40 |
| Rate for Payer: AlohaCare Medicaid |
$255.92
|
| Rate for Payer: AlohaCare Medicare |
$215.82
|
| Rate for Payer: Cash Price |
$756.60
|
| Rate for Payer: Cash Price |
$756.60
|
| Rate for Payer: Cash Price |
$756.60
|
| Rate for Payer: Devoted Health Medicare |
$237.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$396.29
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$237.12
|
| Rate for Payer: Health Management Network Commercial |
$989.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$258.98
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$255.92
|
| Rate for Payer: Ohana Health Plan Medicare |
$215.82
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$300.06
|
|
|
13101-Trunk 2.6-7.5 cm
|
Facility
|
OP
|
$3,028.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
8080027
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$2,937.16 |
| Rate for Payer: AlohaCare Medicaid |
$1,514.00
|
| Rate for Payer: AlohaCare Medicare |
$1,514.00
|
| Rate for Payer: Cash Price |
$1,968.20
|
| Rate for Payer: Cash Price |
$1,968.20
|
| Rate for Payer: Devoted Health Medicare |
$1,665.40
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,514.00
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,876.60
|
| Rate for Payer: Health Management Network Commercial |
$2,573.80
|
| Rate for Payer: Humana Medicare |
$1,514.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,725.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,514.00
|
| Rate for Payer: MDX Hawaii PPO |
$2,937.16
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,514.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,514.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,514.00
|
| Rate for Payer: University Health Alliance Commercial |
$2,207.11
|
|
|
13101-Trunk 2.6-7.5 cm
|
Facility
|
IP
|
$3,028.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
8080027
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,573.80 |
| Max. Negotiated Rate |
$2,937.16 |
| Rate for Payer: Cash Price |
$1,968.20
|
| Rate for Payer: Health Management Network Commercial |
$2,573.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,725.20
|
| Rate for Payer: MDX Hawaii PPO |
$2,937.16
|
|
|
13102 Repair, complex, trunk; each additional 5 cm or less
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
8037211
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$58.71 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$71.40
|
| Rate for Payer: AlohaCare Medicare |
$58.71
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Cash Price |
$201.50
|
| Rate for Payer: Devoted Health Medicare |
$64.58
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$112.37
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$73.32
|
| Rate for Payer: Health Management Network Commercial |
$263.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$70.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$71.40
|
| Rate for Payer: Ohana Health Plan Medicare |
$58.71
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$83.15
|
|
|
13102-Trunk Each Addl 5 cm
|
Facility
|
IP
|
$1,011.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
8080029
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$859.35 |
| Max. Negotiated Rate |
$980.67 |
| Rate for Payer: Cash Price |
$657.15
|
| Rate for Payer: Health Management Network Commercial |
$859.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$909.90
|
| Rate for Payer: MDX Hawaii PPO |
$980.67
|
|
|
13102-Trunk Each Addl 5 cm
|
Facility
|
OP
|
$1,011.00
|
|
|
Service Code
|
HCPCS 13102
|
| Hospital Charge Code |
8080029
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: AlohaCare Medicaid |
$505.50
|
| Rate for Payer: AlohaCare Medicare |
$505.50
|
| Rate for Payer: Cash Price |
$657.15
|
| Rate for Payer: Cash Price |
$657.15
|
| Rate for Payer: Devoted Health Medicare |
$556.05
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$505.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$960.45
|
| Rate for Payer: Health Management Network Commercial |
$859.35
|
| Rate for Payer: Humana Medicare |
$505.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$909.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$505.50
|
| Rate for Payer: MDX Hawaii PPO |
$980.67
|
| Rate for Payer: Ohana Health Plan Medicaid |
$505.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$505.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$505.50
|
| Rate for Payer: University Health Alliance Commercial |
$736.92
|
|
|
13120 Repair complex scalp arms and/or legs 1.1 cm to 2.5 cm
|
Professional
|
Both
|
$951.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
8037212
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$808.35 |
| Rate for Payer: AlohaCare Medicaid |
$240.44
|
| Rate for Payer: AlohaCare Medicare |
$204.09
|
| Rate for Payer: Cash Price |
$618.15
|
| Rate for Payer: Cash Price |
$618.15
|
| Rate for Payer: Cash Price |
$618.15
|
| Rate for Payer: Devoted Health Medicare |
$224.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$372.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.06
|
| Rate for Payer: Health Management Network Commercial |
$808.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$244.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$181.39
|
| Rate for Payer: Kaiser Permanente Commercial |
$209.49
|
| Rate for Payer: Kaiser Permanente Commercial |
$237.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$246.64
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicaid |
$434.26
|
| Rate for Payer: Kaiser Permanente Medicare |
$339.46
|
| Rate for Payer: Kaiser Permanente Medicare |
$246.64
|
| Rate for Payer: Kaiser Permanente Medicare |
$265.97
|
| Rate for Payer: Kaiser Permanente Medicare |
$303.73
|
| Rate for Payer: Kaiser Permanente Medicare |
$181.39
|
| Rate for Payer: Kaiser Permanente Medicare |
$209.49
|
| Rate for Payer: Kaiser Permanente Medicare |
$237.64
|
| Rate for Payer: Ohana Health Plan Medicaid |
$240.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$204.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: University Health Alliance Commercial |
$275.92
|
|
|
13120 Repair complex scalp arms and/or legs 1.1 cm to 2.5 cm
|
Professional
|
Both
|
$951.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
8037212
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$190.06 |
| Max. Negotiated Rate |
$808.35 |
| Rate for Payer: AlohaCare Medicaid |
$240.44
|
| Rate for Payer: AlohaCare Medicare |
$204.09
|
| Rate for Payer: Cash Price |
$618.15
|
| Rate for Payer: Cash Price |
$618.15
|
| Rate for Payer: Devoted Health Medicare |
$224.50
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$240.44
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$372.87
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$204.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$240.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$190.06
|
| Rate for Payer: Health Management Network Commercial |
$808.35
|
| Rate for Payer: Kaiser Permanente Commercial |
$244.91
|
| Rate for Payer: Kaiser Permanente Medicaid |
$244.91
|
| Rate for Payer: Kaiser Permanente Medicare |
$244.91
|
| Rate for Payer: Ohana Health Plan Medicaid |
$240.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$204.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$240.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$204.09
|
| Rate for Payer: University Health Alliance Commercial |
$275.92
|
|
|
13120-Scalp/Arms/Legs 1.1-2.5 cm
|
Facility
|
IP
|
$3,187.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
8080031
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,708.95 |
| Max. Negotiated Rate |
$3,091.39 |
| Rate for Payer: Cash Price |
$2,071.55
|
| Rate for Payer: Health Management Network Commercial |
$2,708.95
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,868.30
|
| Rate for Payer: MDX Hawaii PPO |
$3,091.39
|
|
|
13120-Scalp/Arms/Legs 1.1-2.5 cm
|
Facility
|
OP
|
$3,187.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
8080031
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$3,091.39 |
| Rate for Payer: AlohaCare Medicaid |
$1,593.50
|
| Rate for Payer: AlohaCare Medicare |
$1,593.50
|
| Rate for Payer: Cash Price |
$2,071.55
|
| Rate for Payer: Cash Price |
$2,071.55
|
| Rate for Payer: Devoted Health Medicare |
$1,752.85
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,593.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$3,027.65
|
| Rate for Payer: Health Management Network Commercial |
$2,708.95
|
| Rate for Payer: Humana Medicare |
$1,593.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,868.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,593.50
|
| Rate for Payer: MDX Hawaii PPO |
$3,091.39
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,593.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,593.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,593.50
|
| Rate for Payer: University Health Alliance Commercial |
$2,323.00
|
|
|
13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM TechFee
|
Facility
|
OP
|
$3,037.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
8022662
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$5,160.40 |
| Rate for Payer: AlohaCare Medicaid |
$1,518.50
|
| Rate for Payer: AlohaCare Medicare |
$1,518.50
|
| Rate for Payer: Cash Price |
$1,974.05
|
| Rate for Payer: Cash Price |
$1,974.05
|
| Rate for Payer: Devoted Health Medicare |
$1,670.35
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$469.00
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,600.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$1,518.50
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$450.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$2,885.15
|
| Rate for Payer: Health Management Network Commercial |
$2,581.45
|
| Rate for Payer: Humana Medicare |
$1,518.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,733.30
|
| Rate for Payer: Kaiser Permanente Medicaid |
$937.50
|
| Rate for Payer: Kaiser Permanente Medicare |
$1,518.50
|
| Rate for Payer: MDX Hawaii PPO |
$2,945.89
|
| Rate for Payer: Ohana Health Plan Medicaid |
$1,518.50
|
| Rate for Payer: Ohana Health Plan Medicare |
$1,518.50
|
| Rate for Payer: UnitedHealthcare Medicare |
$1,518.50
|
| Rate for Payer: University Health Alliance Commercial |
$5,160.40
|
|
|
13121 REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM TechFee
|
Facility
|
IP
|
$3,037.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
8022662
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,581.45 |
| Max. Negotiated Rate |
$2,945.89 |
| Rate for Payer: Cash Price |
$1,974.05
|
| Rate for Payer: Health Management Network Commercial |
$2,581.45
|
| Rate for Payer: Kaiser Permanente Commercial |
$2,733.30
|
| Rate for Payer: MDX Hawaii PPO |
$2,945.89
|
|
