Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC LACOSAMIDE

Facility

$227.00

Service Code	HCPCS 80235
Hospital Charge Code	3018023501
Hospital Revenue Code	301
Min. Negotiated Rate	$192.95
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: MDX Hawaii PPO	$220.19

HC LACTATE (LD) (LDH) ENZYME - LDH

Facility

$51.00

Service Code	HCPCS 83615
Hospital Charge Code	3018361501
Hospital Revenue Code	301
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$6.04
Rate for Payer: AlohaCare Medicare	$6.04
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$6.64
Rate for Payer: Hawaii Medical Service Association ABD	$8.35
Rate for Payer: Hawaii Medical Service Association Commercial	$7.55
Rate for Payer: Hawaii Medical Service Association Medicare	$6.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.77
Rate for Payer: Hawaii Western Management Group Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$6.04
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$6.04
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$6.64
Rate for Payer: Ohana Health Plan Medicare	$6.04
Rate for Payer: UnitedHealthcare Medicaid	$8.35
Rate for Payer: UnitedHealthcare Medicare	$6.04
Rate for Payer: University Health Alliance Commercial	$15.61

HC LACTATE (LD) (LDH) ENZYME - LDH

Facility

$51.00

Service Code	HCPCS 83615
Hospital Charge Code	3018361501
Hospital Revenue Code	301
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

HC LACTATE (LD) (LDH) ENZYME - LDH BODY FLUID

Facility

$51.00

Service Code	HCPCS 83615
Hospital Charge Code	3018361502
Hospital Revenue Code	301
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$6.04
Rate for Payer: AlohaCare Medicare	$6.04
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$6.64
Rate for Payer: Hawaii Medical Service Association ABD	$8.35
Rate for Payer: Hawaii Medical Service Association Commercial	$7.55
Rate for Payer: Hawaii Medical Service Association Medicare	$6.04
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.77
Rate for Payer: Hawaii Western Management Group Commercial	$6.04
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$6.04
Rate for Payer: Kaiser Permanente Commercial	$32.13
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$6.04
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$6.64
Rate for Payer: Ohana Health Plan Medicare	$6.04
Rate for Payer: UnitedHealthcare Medicaid	$8.35
Rate for Payer: UnitedHealthcare Medicare	$6.04
Rate for Payer: University Health Alliance Commercial	$15.61

HC LACTATE (LD) (LDH) ENZYME - LDH BODY FLUID

Facility

$51.00

Service Code	HCPCS 83615
Hospital Charge Code	3018361502
Hospital Revenue Code	301
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: MDX Hawaii PPO	$49.47

HC LACTOFERRIN FECAL QUAL SO

Facility

$165.00

Service Code	HCPCS 83630
Hospital Charge Code	3018363001
Hospital Revenue Code	301
Min. Negotiated Rate	$16.45
Max. Negotiated Rate	$160.05
Rate for Payer: AlohaCare Medicaid	$19.70
Rate for Payer: AlohaCare Medicare	$19.70
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Devoted Health Medicare	$21.67
Rate for Payer: Hawaii Medical Service Association ABD	$16.45
Rate for Payer: Hawaii Medical Service Association Commercial	$24.62
Rate for Payer: Hawaii Medical Service Association Medicare	$19.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.68
Rate for Payer: Hawaii Western Management Group Commercial	$19.70
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Humana Medicare	$19.70
Rate for Payer: Kaiser Permanente Commercial	$103.95
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicare	$19.70
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: Ohana Health Plan Medicaid	$21.67
Rate for Payer: Ohana Health Plan Medicare	$19.70
Rate for Payer: UnitedHealthcare Medicaid	$16.45
Rate for Payer: UnitedHealthcare Medicare	$19.70
Rate for Payer: University Health Alliance Commercial	$50.73

HC LACTOFERRIN FECAL QUAL SO

Facility

$165.00

Service Code	HCPCS 83630
Hospital Charge Code	3018363001
Hospital Revenue Code	301
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: MDX Hawaii PPO	$160.05

HC LAMOTRIGINE SO (LAMOT)

Facility

$111.00

Service Code	HCPCS 80175
Hospital Charge Code	3018017501
Hospital Revenue Code	301
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$66.60
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: MDX Hawaii PPO	$107.67

HC LAMOTRIGINE SO (LAMOT)

Facility

$111.00

Service Code	HCPCS 80175
Hospital Charge Code	3018017501
Hospital Revenue Code	301
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$107.67
Rate for Payer: AlohaCare Medicaid	$13.25
Rate for Payer: AlohaCare Medicare	$13.25
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cash Price	$66.60
Rate for Payer: Devoted Health Medicare	$14.57
Rate for Payer: Hawaii Medical Service Association ABD	$11.11
Rate for Payer: Hawaii Medical Service Association Commercial	$16.56
Rate for Payer: Hawaii Medical Service Association Medicare	$13.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.75
Rate for Payer: Hawaii Western Management Group Commercial	$13.25
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Humana Medicare	$13.25
Rate for Payer: Kaiser Permanente Commercial	$69.93
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: Kaiser Permanente Medicare	$13.25
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: Ohana Health Plan Medicaid	$14.57
Rate for Payer: Ohana Health Plan Medicare	$13.25
Rate for Payer: UnitedHealthcare Medicaid	$10.85
Rate for Payer: UnitedHealthcare Medicare	$13.25
Rate for Payer: University Health Alliance Commercial	$33.47

HC LAPS ABD PRTM&OMENTUM DX W/WO SPEC BR/WA SPX

Facility

$22,735.00

Service Code	HCPCS 49320
Hospital Charge Code	3614932001
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$22,052.95
Rate for Payer: AlohaCare Medicaid	$7,141.85
Rate for Payer: AlohaCare Medicare	$7,141.85
Rate for Payer: Cash Price	$13,641.00
Rate for Payer: Cash Price	$13,641.00
Rate for Payer: Cash Price	$13,641.00
Rate for Payer: Devoted Health Medicare	$7,856.03
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,141.85
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Health Management Network Commercial	$19,324.75
Rate for Payer: Humana Medicare	$7,141.85
Rate for Payer: Kaiser Permanente Commercial	$14,323.05
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$7,141.85
Rate for Payer: MDX Hawaii PPO	$22,052.95
Rate for Payer: Ohana Health Plan Medicaid	$7,856.03
Rate for Payer: Ohana Health Plan Medicare	$7,141.85
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$7,141.85
Rate for Payer: University Health Alliance Commercial	$6,743.44

HC LAPS ABD PRTM&OMENTUM DX W/WO SPEC BR/WA SPX

Facility

$22,735.00

Service Code	HCPCS 49320
Hospital Charge Code	3614932001
Hospital Revenue Code	361
Min. Negotiated Rate	$19,324.75
Max. Negotiated Rate	$22,052.95
Rate for Payer: Cash Price	$13,641.00
Rate for Payer: Health Management Network Commercial	$19,324.75
Rate for Payer: MDX Hawaii PPO	$22,052.95

HC LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL

Facility

$6,863.00

Service Code	HCPCS 31530
Hospital Charge Code	4503153001
Hospital Revenue Code	450
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,657.11
Rate for Payer: AlohaCare Medicaid	$2,102.67
Rate for Payer: AlohaCare Medicare	$2,102.67
Rate for Payer: Cash Price	$4,117.80
Rate for Payer: Cash Price	$4,117.80
Rate for Payer: Cash Price	$4,117.80
Rate for Payer: Devoted Health Medicare	$2,312.94
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,102.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$6,519.85
Rate for Payer: Health Management Network Commercial	$5,833.55
Rate for Payer: Humana Medicare	$2,102.67
Rate for Payer: Kaiser Permanente Commercial	$4,323.69
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,102.67
Rate for Payer: MDX Hawaii PPO	$6,657.11
Rate for Payer: Ohana Health Plan Medicaid	$2,312.94
Rate for Payer: Ohana Health Plan Medicare	$2,102.67
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,102.67
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL

Facility

$6,863.00

Service Code	HCPCS 31530
Hospital Charge Code	4503153001
Hospital Revenue Code	450
Min. Negotiated Rate	$5,833.55
Max. Negotiated Rate	$6,657.11
Rate for Payer: Cash Price	$4,117.80
Rate for Payer: Health Management Network Commercial	$5,833.55
Rate for Payer: MDX Hawaii PPO	$6,657.11

HC LARYNGOSCOPY, DIRECT, WITH FOREIGN BODY REMOVAL; CHILD UNDER 5 YEARS

Facility

$756.00

Service Code	HCPCS 31511
Hospital Charge Code	4503151101
Hospital Revenue Code	450
Min. Negotiated Rate	$235.80
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$235.80
Rate for Payer: AlohaCare Medicare	$235.80
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cash Price	$453.60
Rate for Payer: Devoted Health Medicare	$259.38
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$235.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$718.20
Rate for Payer: Health Management Network Commercial	$642.60
Rate for Payer: Humana Medicare	$235.80
Rate for Payer: Kaiser Permanente Commercial	$476.28
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$235.80
Rate for Payer: MDX Hawaii PPO	$733.32
Rate for Payer: Ohana Health Plan Medicaid	$259.38
Rate for Payer: Ohana Health Plan Medicare	$235.80
Rate for Payer: UnitedHealthcare Medicare	$235.80
Rate for Payer: University Health Alliance Commercial	$551.05

HC LARYNGOSCOPY, DIRECT, WITH FOREIGN BODY REMOVAL; CHILD UNDER 5 YEARS

Facility

$756.00

Service Code	HCPCS 31511
Hospital Charge Code	4503151101
Hospital Revenue Code	450
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$733.32
Rate for Payer: Cash Price	$453.60
Rate for Payer: Health Management Network Commercial	$642.60
Rate for Payer: MDX Hawaii PPO	$733.32

HC LARYNGOSCOPY,FLEX FIBER,DIAGNOSTIC

Facility

$773.00

Service Code	HCPCS 31575
Hospital Charge Code	7613157501
Hospital Revenue Code	761
Min. Negotiated Rate	$53.40
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$235.80
Rate for Payer: AlohaCare Medicare	$235.80
Rate for Payer: Cash Price	$463.80
Rate for Payer: Cash Price	$463.80
Rate for Payer: Cash Price	$463.80
Rate for Payer: Devoted Health Medicare	$259.38
Rate for Payer: Hawaii Medical Service Association Commercial	$294.75
Rate for Payer: Hawaii Medical Service Association Medicare	$235.80
Rate for Payer: Hawaii Western Management Group Commercial	$734.35
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Humana Medicare	$235.80
Rate for Payer: Kaiser Permanente Commercial	$486.99
Rate for Payer: Kaiser Permanente Medicaid	$394.23
Rate for Payer: Kaiser Permanente Medicare	$235.80
Rate for Payer: MDX Hawaii PPO	$749.81
Rate for Payer: Ohana Health Plan Medicaid	$259.38
Rate for Payer: Ohana Health Plan Medicare	$235.80
Rate for Payer: UnitedHealthcare Medicaid	$53.40
Rate for Payer: UnitedHealthcare Medicare	$235.80
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC LARYNGOSCOPY,FLEX FIBER,DIAGNOSTIC

Facility

$773.00

Service Code	HCPCS 31575
Hospital Charge Code	7613157501
Hospital Revenue Code	761
Min. Negotiated Rate	$657.05
Max. Negotiated Rate	$749.81
Rate for Payer: Cash Price	$463.80
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: MDX Hawaii PPO	$749.81

HC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY

Facility

$1,545.00

Service Code	HCPCS 31577
Hospital Charge Code	4503157701
Hospital Revenue Code	450
Min. Negotiated Rate	$462.05
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$462.05
Rate for Payer: AlohaCare Medicare	$462.05
Rate for Payer: Cash Price	$927.00
Rate for Payer: Cash Price	$927.00
Rate for Payer: Cash Price	$927.00
Rate for Payer: Devoted Health Medicare	$508.25
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$462.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$1,467.75
Rate for Payer: Health Management Network Commercial	$1,313.25
Rate for Payer: Humana Medicare	$462.05
Rate for Payer: Kaiser Permanente Commercial	$973.35
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$462.05
Rate for Payer: MDX Hawaii PPO	$1,498.65
Rate for Payer: Ohana Health Plan Medicaid	$508.25
Rate for Payer: Ohana Health Plan Medicare	$462.05
Rate for Payer: UnitedHealthcare Medicare	$462.05
Rate for Payer: University Health Alliance Commercial	$1,126.15

HC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY

Facility

$1,545.00

Service Code	HCPCS 31577
Hospital Charge Code	4503157701
Hospital Revenue Code	450
Min. Negotiated Rate	$1,313.25
Max. Negotiated Rate	$1,498.65
Rate for Payer: Cash Price	$927.00
Rate for Payer: Health Management Network Commercial	$1,313.25
Rate for Payer: MDX Hawaii PPO	$1,498.65

HC LAYR CLOS WND FACE,FACIAL 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12055
Hospital Charge Code	7611205501
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,510.50
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,001.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC LAYR CLOS WND FACE,FACIAL 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12055
Hospital Charge Code	7611205501
Hospital Revenue Code	450
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$1,542.30
Rate for Payer: Cash Price	$954.00
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: MDX Hawaii PPO	$1,542.30

HC LAYR CLOS WND FACE,FACIAL 20.1-30 CM

Facility

$1,557.00

Service Code	HCPCS 12056
Hospital Charge Code	3611205601
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$934.20
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$934.20
Rate for Payer: Cash Price	$934.20
Rate for Payer: Cash Price	$934.20
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,479.15
Rate for Payer: Health Management Network Commercial	$1,323.45
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$980.91
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,510.29
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,134.90

HC LAYR CLOS WND FACE,FACIAL 20.1-30 CM

Facility

$1,557.00

Service Code	HCPCS 12056
Hospital Charge Code	3611205601
Hospital Revenue Code	450
Min. Negotiated Rate	$1,323.45
Max. Negotiated Rate	$1,510.29
Rate for Payer: Cash Price	$934.20
Rate for Payer: Health Management Network Commercial	$1,323.45
Rate for Payer: MDX Hawaii PPO	$1,510.29

HC LAYR CLOS WND FACE,FACIAL 2.5-5 CM

Facility

$1,590.00

Service Code	HCPCS 12052
Hospital Charge Code	4501205201
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association ABD	$569.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,510.50
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,001.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC LAYR CLOS WND FACE,FACIAL 2.5-5 CM

Facility

$1,590.00

Service Code	HCPCS 12052
Hospital Charge Code	4501205201
Hospital Revenue Code	450
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$1,542.30
Rate for Payer: Cash Price	$954.00
Rate for Payer: Health Management Network Commercial	$1,351.50
Rate for Payer: MDX Hawaii PPO	$1,542.30

Know your out-of-pocket cost for care.

All Charges