Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC LAYR CLOS WND FACE,FACIAL <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12051
Hospital Charge Code	4501205101
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$4,035.20
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	$4,035.20

HC LAYR CLOS WND FACE,FACIAL <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12051
Hospital Charge Code	4501205101
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 >30 CM

Facility

$1,590.00

Service Code	HCPCS 12057
Hospital Charge Code	3611205701
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 >30 CM

Facility

$1,590.00

Service Code	HCPCS 12057
Hospital Charge Code	3611205701
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 5.1-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12053
Hospital Charge Code	4501205301
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 5.1-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12053
Hospital Charge Code	4501205301
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 7.6-12.5 CM

Facility

$1,590.00

Service Code	HCPCS 12054
Hospital Charge Code	4501205401
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 7.6-12.5 CM

Facility

$1,590.00

Service Code	HCPCS 12054
Hospital Charge Code	4501205401
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 REST BODY <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12041
Hospital Charge Code	4501204101
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 REST BODY <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12041
Hospital Charge Code	4501204101
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 REST BODY 2.6-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12042
Hospital Charge Code	4501204201
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 REST BODY 2.6-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12042
Hospital Charge Code	4501204201
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 REST BODY 7.6-12.5 CM

Facility

$2,436.00

Service Code	HCPCS 12044
Hospital Charge Code	4501204401
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$1,775.60

HC LAYR CLOS WND REST BODY 7.6-12.5 CM

Facility

$2,436.00

Service Code	HCPCS 12044
Hospital Charge Code	4501204401
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC LAYR CLOS WND TRUNK,ARM,LEG 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12035
Hospital Charge Code	4501203501
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$5,160.40
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	$5,160.40

HC LAYR CLOS WND TRUNK,ARM,LEG 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12035
Hospital Charge Code	4501203501
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 TRUNK,ARM,LEG 20.1-30 CM

Facility

$2,436.00

Service Code	HCPCS 12036
Hospital Charge Code	7611203601
Hospital Revenue Code	450
Min. Negotiated Rate	$2,070.60
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92

HC LAYR CLOS WND TRUNK,ARM,LEG 20.1-30 CM

Facility

$2,436.00

Service Code	HCPCS 12036
Hospital Charge Code	7611203601
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicare	$873.10
Rate for Payer: University Health Alliance Commercial	$1,775.60

HC LAYR CLOS WND TRUNK,ARM,LEG <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12031
Hospital Charge Code	4501203101
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 TRUNK,ARM,LEG <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12031
Hospital Charge Code	4501203101
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 TRUNK,ARM,LEG 2.6-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12032
Hospital Charge Code	7611203201
Hospital Revenue Code	761
Min. Negotiated Rate	$104.83
Max. Negotiated Rate	$4,035.20
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: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association Commercial	$600.29
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
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	$810.90
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 Medicaid	$104.83
Rate for Payer: UnitedHealthcare Medicare	$480.23
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12032
Hospital Charge Code	7611203201
Hospital Revenue Code	761
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 TRUNK,ARM,LEG 7.6-12.5 CM

Facility

$1,590.00

Service Code	HCPCS 12034
Hospital Charge Code	4501203401
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 TRUNK,ARM,LEG 7.6-12.5 CM

Facility

$1,590.00

Service Code	HCPCS 12034
Hospital Charge Code	4501203401
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$5,160.40
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	$5,160.40

HC L&D OP VISIT EP LEVEL 1

Facility

$528.00

Service Code	HCPCS 99211
Hospital Charge Code	7619921101
Hospital Revenue Code	761
Min. Negotiated Rate	$9.17
Max. Negotiated Rate	$512.16
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Hawaii Western Management Group Commercial	$501.60
Rate for Payer: Health Management Network Commercial	$448.80
Rate for Payer: Kaiser Permanente Commercial	$332.64
Rate for Payer: Kaiser Permanente Medicaid	$269.28
Rate for Payer: MDX Hawaii PPO	$512.16
Rate for Payer: UnitedHealthcare Medicaid	$9.17
Rate for Payer: University Health Alliance Commercial	$384.86

Know your out-of-pocket cost for care.

All Charges