|
15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
8037238
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$735.82
|
| Rate for Payer: AlohaCare Medicare |
$671.05
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$738.15
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,139.64
|
| 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 |
$532.74
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$805.26
|
| 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 |
$735.82
|
| Rate for Payer: Ohana Health Plan Medicare |
$671.05
|
| 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 |
$843.33
|
|
|
15101 Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm
|
Professional
|
Both
|
$545.00
|
|
|
Service Code
|
HCPCS 15101
|
| Hospital Charge Code |
8037239
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$99.54 |
| Max. Negotiated Rate |
$463.25 |
| Rate for Payer: AlohaCare Medicaid |
$110.25
|
| Rate for Payer: AlohaCare Medicare |
$99.54
|
| Rate for Payer: Cash Price |
$354.25
|
| Rate for Payer: Cash Price |
$354.25
|
| Rate for Payer: Cash Price |
$354.25
|
| Rate for Payer: Devoted Health Medicare |
$109.49
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$176.01
|
| 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 |
$119.08
|
| Rate for Payer: Health Management Network Commercial |
$463.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$119.45
|
| 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 |
$110.25
|
| Rate for Payer: Ohana Health Plan Medicare |
$99.54
|
| 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 |
$130.25
|
|
|
15115 Epidermal autograft, face/scalp/neck/genitalia/hands/feet; first 100 sq cm
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
8037240
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$709.37
|
| Rate for Payer: AlohaCare Medicare |
$654.24
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$719.66
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,085.10
|
| 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 |
$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 Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$785.09
|
| 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 |
$303.73
|
| 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 |
$709.37
|
| Rate for Payer: Ohana Health Plan Medicare |
$654.24
|
| 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 |
$802.97
|
|
|
15120 Split-thickness autograft, face/scalp/neck/genitalia/hands/feet; first 100 sq cm
|
Professional
|
Both
|
$4,932.00
|
|
|
Service Code
|
HCPCS 15120
|
| Hospital Charge Code |
8037241
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$4,192.20 |
| Rate for Payer: AlohaCare Medicaid |
$709.84
|
| Rate for Payer: AlohaCare Medicare |
$623.47
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Devoted Health Medicare |
$685.82
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,094.54
|
| 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 |
$476.32
|
| Rate for Payer: Health Management Network Commercial |
$4,192.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$748.16
|
| 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 |
$709.84
|
| Rate for Payer: Ohana Health Plan Medicare |
$623.47
|
| 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 |
$809.96
|
|
|
15121 Split-thickness autograft, face/scalp/neck/genitalia/hands/feet; each additional 100 sq cm
|
Professional
|
Both
|
$710.00
|
|
|
Service Code
|
HCPCS 15121
|
| Hospital Charge Code |
8037242
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$118.83 |
| Max. Negotiated Rate |
$603.50 |
| Rate for Payer: AlohaCare Medicaid |
$132.18
|
| Rate for Payer: AlohaCare Medicare |
$118.83
|
| Rate for Payer: Cash Price |
$461.50
|
| Rate for Payer: Cash Price |
$461.50
|
| Rate for Payer: Cash Price |
$461.50
|
| Rate for Payer: Devoted Health Medicare |
$130.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$220.56
|
| 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 |
$163.54
|
| Rate for Payer: Health Management Network Commercial |
$603.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$142.60
|
| 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 |
$132.18
|
| Rate for Payer: Ohana Health Plan Medicare |
$118.83
|
| 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 |
$157.78
|
|
|
15135 Dermal autograft, face/scalp/neck/genitalia/hands/feet; first 100 sq cm
|
Professional
|
Both
|
$4,932.00
|
|
|
Service Code
|
HCPCS 15135
|
| Hospital Charge Code |
8037243
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$4,192.20 |
| Rate for Payer: AlohaCare Medicaid |
$783.93
|
| Rate for Payer: AlohaCare Medicare |
$687.17
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Devoted Health Medicare |
$755.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,206.90
|
| 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 |
$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 Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Health Management Network Commercial |
$4,192.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$824.60
|
| 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 |
$303.73
|
| 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 |
$783.93
|
| Rate for Payer: Ohana Health Plan Medicare |
$687.17
|
| 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 |
$893.11
|
|
|
15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15200
|
| Hospital Charge Code |
8037244
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$696.83
|
| Rate for Payer: AlohaCare Medicare |
$619.37
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$681.31
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,070.82
|
| 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 |
$381.42
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$743.24
|
| 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 |
$696.83
|
| Rate for Payer: Ohana Health Plan Medicare |
$619.37
|
| 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 |
$792.41
|
|
|
15201 Full thickness graft, free, including direct closure of donor site, trunk; ea addtnl 20 sq cm
|
Professional
|
Both
|
$435.00
|
|
|
Service Code
|
HCPCS 15201
|
| Hospital Charge Code |
8037245
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$63.49 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$75.38
|
| Rate for Payer: AlohaCare Medicare |
$63.49
|
| Rate for Payer: Cash Price |
$282.75
|
| Rate for Payer: Cash Price |
$282.75
|
| Rate for Payer: Cash Price |
$282.75
|
| Rate for Payer: Devoted Health Medicare |
$69.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$117.72
|
| 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 |
$92.04
|
| Rate for Payer: Health Management Network Commercial |
$369.75
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$76.19
|
| 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 |
$75.38
|
| Rate for Payer: Ohana Health Plan Medicare |
$63.49
|
| 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 |
$87.11
|
|
|
15220 Full thickness graft, free, including direct closure of donor site, scalp/arms/legs; <20 sq cm
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15220
|
| Hospital Charge Code |
8037246
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$638.04
|
| Rate for Payer: AlohaCare Medicare |
$554.45
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$609.89
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$975.08
|
| 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 |
$398.58
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$665.34
|
| 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 |
$638.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$554.45
|
| 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 |
$721.56
|
|
|
15221 Full thickness graft, free, including closure of donor site, scalp/arms/legs; ea addl 20 sq cm
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
HCPCS 15221
|
| Hospital Charge Code |
8037247
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$56.66 |
| Max. Negotiated Rate |
$434.26 |
| Rate for Payer: AlohaCare Medicaid |
$68.39
|
| Rate for Payer: AlohaCare Medicare |
$56.66
|
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: Cash Price |
$263.25
|
| Rate for Payer: Devoted Health Medicare |
$62.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$107.37
|
| 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 |
$85.80
|
| Rate for Payer: Health Management Network Commercial |
$344.25
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$67.99
|
| 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 |
$68.39
|
| Rate for Payer: Ohana Health Plan Medicare |
$56.66
|
| 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 |
$79.45
|
|
|
15240 Full thickness graft, free; forehead, cheeks, chin, mouth, neck, axillae, hands; <20 sq cm
|
Professional
|
Both
|
$2,694.00
|
|
|
Service Code
|
HCPCS 15240
|
| Hospital Charge Code |
8037248
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,289.90 |
| Rate for Payer: AlohaCare Medicaid |
$835.06
|
| Rate for Payer: AlohaCare Medicare |
$722.48
|
| Rate for Payer: Cash Price |
$1,751.10
|
| Rate for Payer: Cash Price |
$1,751.10
|
| Rate for Payer: Cash Price |
$1,751.10
|
| Rate for Payer: Devoted Health Medicare |
$794.73
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,273.49
|
| 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 |
$606.84
|
| Rate for Payer: Health Management Network Commercial |
$2,289.90
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$866.98
|
| 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 |
$835.06
|
| Rate for Payer: Ohana Health Plan Medicare |
$722.48
|
| 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 |
$942.38
|
|
|
15241 Full thickness graft; forehead/cheeks/chin/mouth/neck/axil/gen/hands/feet; ea add 20 sq cm
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 15241
|
| Hospital Charge Code |
8037249
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$88.09 |
| Max. Negotiated Rate |
$212.50 |
| Rate for Payer: AlohaCare Medicaid |
$106.33
|
| Rate for Payer: AlohaCare Medicare |
$88.09
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Devoted Health Medicare |
$96.90
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$106.33
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$163.70
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$88.09
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$106.33
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$127.66
|
| Rate for Payer: Health Management Network Commercial |
$212.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$105.71
|
| Rate for Payer: Kaiser Permanente Medicaid |
$105.71
|
| Rate for Payer: Kaiser Permanente Medicare |
$105.71
|
| Rate for Payer: Ohana Health Plan Medicaid |
$106.33
|
| Rate for Payer: Ohana Health Plan Medicare |
$88.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$106.33
|
| Rate for Payer: UnitedHealthcare Medicare |
$88.09
|
| Rate for Payer: University Health Alliance Commercial |
$121.13
|
|
|
15260 Full thickness graft, free, direct closure of donor site, nose/ears/eyelids/lips; <20 sq cm
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15260
|
| Hospital Charge Code |
8037250
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$686.40 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$884.63
|
| Rate for Payer: AlohaCare Medicare |
$750.78
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$825.86
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$884.63
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,350.12
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$750.78
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$884.63
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$686.40
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$900.94
|
| Rate for Payer: Kaiser Permanente Medicaid |
$900.94
|
| Rate for Payer: Kaiser Permanente Medicare |
$900.94
|
| Rate for Payer: Ohana Health Plan Medicaid |
$884.63
|
| Rate for Payer: Ohana Health Plan Medicare |
$750.78
|
| Rate for Payer: UnitedHealthcare Medicaid |
$884.63
|
| Rate for Payer: UnitedHealthcare Medicare |
$750.78
|
| Rate for Payer: University Health Alliance Commercial |
$999.09
|
|
|
15261 Full thickness graft, free, closure of donor site, nose/ears/eyelids/lips; ea add 20 sq cm
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 15261
|
| Hospital Charge Code |
8037251
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$112.46 |
| Max. Negotiated Rate |
$213.81 |
| Rate for Payer: AlohaCare Medicaid |
$136.23
|
| Rate for Payer: AlohaCare Medicare |
$112.46
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Devoted Health Medicare |
$123.71
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$136.23
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$213.81
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$112.46
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$136.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$150.28
|
| Rate for Payer: Health Management Network Commercial |
$170.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$134.95
|
| Rate for Payer: Kaiser Permanente Medicaid |
$134.95
|
| Rate for Payer: Kaiser Permanente Medicare |
$134.95
|
| Rate for Payer: Ohana Health Plan Medicaid |
$136.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$112.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$136.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$112.46
|
| Rate for Payer: University Health Alliance Commercial |
$158.22
|
|
|
15271 Application of skin graft to trunk/arms/legs, up to 100 sq cm; first 25 sq cm
|
Professional
|
Both
|
$1,029.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
8037252
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$74.85 |
| Max. Negotiated Rate |
$874.65 |
| Rate for Payer: AlohaCare Medicaid |
$83.87
|
| Rate for Payer: AlohaCare Medicare |
$74.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Devoted Health Medicare |
$82.33
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$83.87
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$130.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$74.85
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$83.87
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$153.40
|
| Rate for Payer: Health Management Network Commercial |
$874.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$89.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$89.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$89.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$83.87
|
| Rate for Payer: Ohana Health Plan Medicare |
$74.85
|
| Rate for Payer: UnitedHealthcare Medicaid |
$83.87
|
| Rate for Payer: UnitedHealthcare Medicare |
$74.85
|
| Rate for Payer: University Health Alliance Commercial |
$91.51
|
|
|
15272 Application of skin graft to trunk/arms/legs, up to 100 sq cm; ea add 25 sq cm
|
Professional
|
Both
|
$38.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
8037253
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$32.30 |
| Rate for Payer: AlohaCare Medicaid |
$16.51
|
| Rate for Payer: AlohaCare Medicare |
$14.31
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Cash Price |
$24.70
|
| Rate for Payer: Devoted Health Medicare |
$15.74
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$16.51
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$26.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$14.31
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$16.51
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$29.12
|
| Rate for Payer: Health Management Network Commercial |
$32.30
|
| Rate for Payer: Kaiser Permanente Commercial |
$17.17
|
| Rate for Payer: Kaiser Permanente Medicaid |
$17.17
|
| Rate for Payer: Kaiser Permanente Medicare |
$17.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$16.51
|
| Rate for Payer: Ohana Health Plan Medicare |
$14.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.51
|
| Rate for Payer: UnitedHealthcare Medicare |
$14.31
|
| Rate for Payer: University Health Alliance Commercial |
$18.02
|
|
|
15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater th
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15273
|
| Hospital Charge Code |
8118447
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$168.04 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$191.95
|
| Rate for Payer: AlohaCare Medicare |
$168.04
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$184.84
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$191.95
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$323.59
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$168.04
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$191.95
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$319.54
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$201.65
|
| Rate for Payer: Kaiser Permanente Medicaid |
$201.65
|
| Rate for Payer: Kaiser Permanente Medicare |
$201.65
|
| Rate for Payer: Ohana Health Plan Medicaid |
$191.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$168.04
|
| Rate for Payer: UnitedHealthcare Medicaid |
$191.95
|
| Rate for Payer: UnitedHealthcare Medicare |
$168.04
|
| Rate for Payer: University Health Alliance Commercial |
$225.96
|
|
|
15274 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater th
|
Professional
|
Both
|
$122.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
8118448
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$37.70 |
| Max. Negotiated Rate |
$103.70 |
| Rate for Payer: AlohaCare Medicaid |
$43.19
|
| Rate for Payer: AlohaCare Medicare |
$37.70
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Cash Price |
$79.30
|
| Rate for Payer: Devoted Health Medicare |
$41.47
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$43.19
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$73.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$37.70
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$43.19
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$76.70
|
| Rate for Payer: Health Management Network Commercial |
$103.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$45.24
|
| Rate for Payer: Kaiser Permanente Medicaid |
$45.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$45.24
|
| Rate for Payer: Ohana Health Plan Medicaid |
$43.19
|
| Rate for Payer: Ohana Health Plan Medicare |
$37.70
|
| Rate for Payer: UnitedHealthcare Medicaid |
$43.19
|
| Rate for Payer: UnitedHealthcare Medicare |
$37.70
|
| Rate for Payer: University Health Alliance Commercial |
$51.52
|
|
|
15275 Application of skin graft to face/neck/genitalia/hands/feet, up to 100 sq cm; first 25 sq cm
|
Professional
|
Both
|
$1,029.00
|
|
|
Service Code
|
HCPCS 15275
|
| Hospital Charge Code |
8037254
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$83.83 |
| Max. Negotiated Rate |
$874.65 |
| Rate for Payer: AlohaCare Medicaid |
$93.15
|
| Rate for Payer: AlohaCare Medicare |
$83.83
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Cash Price |
$668.85
|
| Rate for Payer: Devoted Health Medicare |
$92.21
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$93.15
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$145.08
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$83.83
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$93.15
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$161.98
|
| Rate for Payer: Health Management Network Commercial |
$874.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$100.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$100.60
|
| Rate for Payer: Kaiser Permanente Medicare |
$100.60
|
| Rate for Payer: Ohana Health Plan Medicaid |
$93.15
|
| Rate for Payer: Ohana Health Plan Medicare |
$83.83
|
| Rate for Payer: UnitedHealthcare Medicaid |
$93.15
|
| Rate for Payer: UnitedHealthcare Medicare |
$83.83
|
| Rate for Payer: University Health Alliance Commercial |
$101.92
|
|
|
15276 Application of skin graft to face/neck/genitalia/hands/feet, up to 100 sq cm; ea add 25 sq cm
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
HCPCS 15276
|
| Hospital Charge Code |
8037255
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$21.52 |
| Max. Negotiated Rate |
$41.65 |
| Rate for Payer: AlohaCare Medicaid |
$24.45
|
| Rate for Payer: AlohaCare Medicare |
$21.52
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: Devoted Health Medicare |
$23.67
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$24.45
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$39.11
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$21.52
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$24.45
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$36.66
|
| Rate for Payer: Health Management Network Commercial |
$41.65
|
| Rate for Payer: Kaiser Permanente Commercial |
$25.82
|
| Rate for Payer: Kaiser Permanente Medicaid |
$25.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$25.82
|
| Rate for Payer: Ohana Health Plan Medicaid |
$24.45
|
| Rate for Payer: Ohana Health Plan Medicare |
$21.52
|
| Rate for Payer: UnitedHealthcare Medicaid |
$24.45
|
| Rate for Payer: UnitedHealthcare Medicare |
$21.52
|
| Rate for Payer: University Health Alliance Commercial |
$28.94
|
|
|
15277 App of skin sub grft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, fee
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
8118449
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$193.36 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$218.88
|
| Rate for Payer: AlohaCare Medicare |
$193.36
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$212.70
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$218.88
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$348.03
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$193.36
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$218.88
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$346.06
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$232.03
|
| Rate for Payer: Kaiser Permanente Medicaid |
$232.03
|
| Rate for Payer: Kaiser Permanente Medicare |
$232.03
|
| Rate for Payer: Ohana Health Plan Medicaid |
$218.88
|
| Rate for Payer: Ohana Health Plan Medicare |
$193.36
|
| Rate for Payer: UnitedHealthcare Medicaid |
$218.88
|
| Rate for Payer: UnitedHealthcare Medicare |
$193.36
|
| Rate for Payer: University Health Alliance Commercial |
$257.54
|
|
|
15278 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit
|
Professional
|
Both
|
$144.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
8118450
|
|
Hospital Revenue Code
|
975
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: AlohaCare Medicaid |
$54.23
|
| Rate for Payer: AlohaCare Medicare |
$47.23
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Devoted Health Medicare |
$51.95
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$54.23
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$87.32
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$47.23
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$54.23
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$91.00
|
| Rate for Payer: Health Management Network Commercial |
$122.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$56.68
|
| Rate for Payer: Kaiser Permanente Medicaid |
$56.68
|
| Rate for Payer: Kaiser Permanente Medicare |
$56.68
|
| Rate for Payer: Ohana Health Plan Medicaid |
$54.23
|
| Rate for Payer: Ohana Health Plan Medicare |
$47.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$54.23
|
| Rate for Payer: UnitedHealthcare Medicare |
$47.23
|
| Rate for Payer: University Health Alliance Commercial |
$64.61
|
|
|
15570 Formation of direct or tubed pedicle, with or without transfer; trunk
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15570
|
| Hospital Charge Code |
8037256
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$748.03
|
| Rate for Payer: AlohaCare Medicare |
$682.23
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$750.45
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,165.14
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$181.39
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$339.46
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$303.73
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$265.97
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$246.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$237.64
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$209.49
|
| Rate for Payer: Hawaii Medical Service Association Non-ABD |
$434.26
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$466.96
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$818.68
|
| Rate for Payer: Kaiser Permanente Commercial |
$265.97
|
| Rate for Payer: Kaiser Permanente Commercial |
$339.46
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| 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 Medicaid |
$434.26
|
| 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: 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 |
$339.46
|
| Rate for Payer: Ohana Health Plan Medicaid |
$748.03
|
| Rate for Payer: Ohana Health Plan Medicare |
$682.23
|
| Rate for Payer: UnitedHealthcare Medicaid |
$434.26
|
| Rate for Payer: UnitedHealthcare Medicare |
$181.39
|
| Rate for Payer: UnitedHealthcare Medicare |
$246.64
|
| Rate for Payer: UnitedHealthcare Medicare |
$303.73
|
| Rate for Payer: UnitedHealthcare Medicare |
$339.46
|
| Rate for Payer: UnitedHealthcare Medicare |
$265.97
|
| Rate for Payer: UnitedHealthcare Medicare |
$209.49
|
| Rate for Payer: UnitedHealthcare Medicare |
$237.64
|
| Rate for Payer: University Health Alliance Commercial |
$862.20
|
|
|
15572 Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs
|
Professional
|
Both
|
$4,932.00
|
|
|
Service Code
|
HCPCS 15572
|
| Hospital Charge Code |
8037257
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$4,192.20 |
| Rate for Payer: AlohaCare Medicaid |
$761.95
|
| Rate for Payer: AlohaCare Medicare |
$683.85
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Cash Price |
$3,205.80
|
| Rate for Payer: Devoted Health Medicare |
$752.24
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,167.80
|
| 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 |
$460.46
|
| Rate for Payer: Health Management Network Commercial |
$4,192.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$820.62
|
| 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 |
$761.95
|
| Rate for Payer: Ohana Health Plan Medicare |
$683.85
|
| 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 |
$864.17
|
|
|
15574 Formation of direct or tubed pedicle, w/ or w/o transfer; face/neck/axil/gen/hands/feet
|
Professional
|
Both
|
$2,872.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
8037258
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$181.39 |
| Max. Negotiated Rate |
$2,441.20 |
| Rate for Payer: AlohaCare Medicaid |
$764.48
|
| Rate for Payer: AlohaCare Medicare |
$651.01
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Cash Price |
$1,866.80
|
| Rate for Payer: Devoted Health Medicare |
$716.11
|
| Rate for Payer: Hawaii Medical Service Association ABD |
$434.26
|
| Rate for Payer: Hawaii Medical Service Association Commercial |
$1,177.01
|
| 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 |
$475.02
|
| Rate for Payer: Health Management Network Commercial |
$2,441.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$303.73
|
| Rate for Payer: Kaiser Permanente Commercial |
$781.21
|
| 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 |
$764.48
|
| Rate for Payer: Ohana Health Plan Medicare |
$651.01
|
| 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 |
$870.98
|
|
