Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC REMOVE RENAL TUBE W/FLUORO

Facility

$2,656.00

Service Code	HCPCS 50389
Hospital Charge Code	3615038901
Hospital Revenue Code	361
Min. Negotiated Rate	$2,257.60
Max. Negotiated Rate	$2,576.32
Rate for Payer: Cash Price	$1,593.60
Rate for Payer: Health Management Network Commercial	$2,257.60
Rate for Payer: MDX Hawaii PPO	$2,576.32

HC REMV EXT CANAL FOREIGN BODY

Facility

$513.00

Service Code	HCPCS 69200
Hospital Charge Code	7616920001
Hospital Revenue Code	761
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$497.61
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association Commercial	$196.47
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$261.63
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicaid	$35.80
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$373.93

HC REMV EXT CANAL FOREIGN BODY

Facility

$513.00

Service Code	HCPCS 69200
Hospital Charge Code	7616920001
Hospital Revenue Code	761
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

HC REMV F.B.,EYE,CORNEA,NO SLIT

Facility

$1,588.00

Service Code	HCPCS 65220
Hospital Charge Code	4506522001
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$527.74
Rate for Payer: AlohaCare Medicare	$527.74
Rate for Payer: Cash Price	$952.80
Rate for Payer: Cash Price	$952.80
Rate for Payer: Cash Price	$952.80
Rate for Payer: Cash Price	$952.80
Rate for Payer: Devoted Health Medicare	$580.51
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	$527.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,508.60
Rate for Payer: Health Management Network Commercial	$1,349.80
Rate for Payer: Humana Medicare	$527.74
Rate for Payer: Kaiser Permanente Commercial	$1,000.44
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$527.74
Rate for Payer: MDX Hawaii PPO	$1,540.36
Rate for Payer: Ohana Health Plan Medicaid	$580.51
Rate for Payer: Ohana Health Plan Medicare	$527.74
Rate for Payer: UnitedHealthcare Medicare	$527.74
Rate for Payer: University Health Alliance Commercial	$1,157.49

HC REMV F.B.,EYE,CORNEA,NO SLIT

Facility

$1,588.00

Service Code	HCPCS 65220
Hospital Charge Code	4506522001
Hospital Revenue Code	450
Min. Negotiated Rate	$1,349.80
Max. Negotiated Rate	$1,540.36
Rate for Payer: Cash Price	$952.80
Rate for Payer: Health Management Network Commercial	$1,349.80
Rate for Payer: MDX Hawaii PPO	$1,540.36

HC REMV F.B.,EYE,CORNEA,SLIT LAMP

Facility

$513.00

Service Code	HCPCS 65222
Hospital Charge Code	4506522201
Hospital Revenue Code	450
Min. Negotiated Rate	$157.18
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$172.90
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$373.93

HC REMV F.B.,EYE,CORNEA,SLIT LAMP

Facility

$513.00

Service Code	HCPCS 65222
Hospital Charge Code	4506522201
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

HC REMV F.B.,EYE,EMBED CONJUNC

Facility

$1,588.00

Service Code	HCPCS 65210
Hospital Charge Code	3616521001
Hospital Revenue Code	450
Min. Negotiated Rate	$1,349.80
Max. Negotiated Rate	$1,540.36
Rate for Payer: Cash Price	$952.80
Rate for Payer: Health Management Network Commercial	$1,349.80
Rate for Payer: MDX Hawaii PPO	$1,540.36

HC REMV F.B.,EYE,EMBED CONJUNC

Facility

$1,588.00

Service Code	HCPCS 65210
Hospital Charge Code	3616521001
Hospital Revenue Code	450
Min. Negotiated Rate	$527.74
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$527.74
Rate for Payer: AlohaCare Medicare	$527.74
Rate for Payer: Cash Price	$952.80
Rate for Payer: Cash Price	$952.80
Rate for Payer: Cash Price	$952.80
Rate for Payer: Devoted Health Medicare	$580.51
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	$527.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$1,508.60
Rate for Payer: Health Management Network Commercial	$1,349.80
Rate for Payer: Humana Medicare	$527.74
Rate for Payer: Kaiser Permanente Commercial	$1,000.44
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$527.74
Rate for Payer: MDX Hawaii PPO	$1,540.36
Rate for Payer: Ohana Health Plan Medicaid	$580.51
Rate for Payer: Ohana Health Plan Medicare	$527.74
Rate for Payer: UnitedHealthcare Medicare	$527.74
Rate for Payer: University Health Alliance Commercial	$1,157.49

HC REMV F.B.,EYE,SUPERF CONJUNC

Facility

$513.00

Service Code	HCPCS 65205
Hospital Charge Code	4506520501
Hospital Revenue Code	450
Min. Negotiated Rate	$157.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$157.18
Rate for Payer: AlohaCare Medicare	$157.18
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Devoted Health Medicare	$172.90
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	$157.18
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$157.18
Rate for Payer: Kaiser Permanente Commercial	$323.19
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$157.18
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$172.90
Rate for Payer: Ohana Health Plan Medicare	$157.18
Rate for Payer: UnitedHealthcare Medicare	$157.18
Rate for Payer: University Health Alliance Commercial	$373.93

HC REMV F.B.,EYE,SUPERF CONJUNC

Facility

$513.00

Service Code	HCPCS 65205
Hospital Charge Code	4506520501
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$307.80
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: MDX Hawaii PPO	$497.61

HC REMV FOOT FOREIGN BODY,SUBCUTANEOUS

Facility

$2,800.00

Service Code	HCPCS 28190
Hospital Charge Code	4502819001
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$836.55
Rate for Payer: AlohaCare Medicare	$836.55
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Devoted Health Medicare	$920.21
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	$836.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: Humana Medicare	$836.55
Rate for Payer: Kaiser Permanente Commercial	$1,764.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$836.55
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: Ohana Health Plan Medicaid	$920.21
Rate for Payer: Ohana Health Plan Medicare	$836.55
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$836.55
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC REMV FOOT FOREIGN BODY,SUBCUTANEOUS

Facility

$2,800.00

Service Code	HCPCS 28190
Hospital Charge Code	4502819001
Hospital Revenue Code	450
Min. Negotiated Rate	$2,380.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: MDX Hawaii PPO	$2,716.00

HC RENAL FUNCTION PANEL - BUNDLED CHARGE

Facility

$73.00

Service Code	HCPCS 80069
Hospital Charge Code	3018006901
Hospital Revenue Code	301
Min. Negotiated Rate	$62.05
Max. Negotiated Rate	$70.81
Rate for Payer: Cash Price	$43.80
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: MDX Hawaii PPO	$70.81

HC RENAL FUNCTION PANEL - BUNDLED CHARGE

Facility

$73.00

Service Code	HCPCS 80069
Hospital Charge Code	3018006901
Hospital Revenue Code	301
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$70.81
Rate for Payer: AlohaCare Medicaid	$8.68
Rate for Payer: AlohaCare Medicare	$8.68
Rate for Payer: Cash Price	$43.80
Rate for Payer: Cash Price	$43.80
Rate for Payer: Devoted Health Medicare	$9.55
Rate for Payer: Hawaii Medical Service Association ABD	$12.00
Rate for Payer: Hawaii Medical Service Association Commercial	$10.85
Rate for Payer: Hawaii Medical Service Association Medicare	$8.68
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.60
Rate for Payer: Hawaii Western Management Group Commercial	$8.68
Rate for Payer: Health Management Network Commercial	$62.05
Rate for Payer: Humana Medicare	$8.68
Rate for Payer: Kaiser Permanente Commercial	$45.99
Rate for Payer: Kaiser Permanente Medicaid	$37.23
Rate for Payer: Kaiser Permanente Medicare	$8.68
Rate for Payer: MDX Hawaii PPO	$70.81
Rate for Payer: Ohana Health Plan Medicaid	$9.55
Rate for Payer: Ohana Health Plan Medicare	$8.68
Rate for Payer: UnitedHealthcare Medicaid	$12.00
Rate for Payer: UnitedHealthcare Medicare	$8.68
Rate for Payer: University Health Alliance Commercial	$22.44

HC RENAL FUNCTION STUDY - NM KIDNEY GFR

Facility

$1,999.00

Service Code	HCPCS 78725
Hospital Charge Code	3417872501
Hospital Revenue Code	341
Min. Negotiated Rate	$59.03
Max. Negotiated Rate	$1,939.03
Rate for Payer: AlohaCare Medicaid	$472.27
Rate for Payer: AlohaCare Medicare	$472.27
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Devoted Health Medicare	$519.50
Rate for Payer: Hawaii Medical Service Association ABD	$59.03
Rate for Payer: Hawaii Medical Service Association Commercial	$590.34
Rate for Payer: Hawaii Medical Service Association Medicare	$472.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$63.93
Rate for Payer: Hawaii Western Management Group Commercial	$472.27
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: Humana Medicare	$472.27
Rate for Payer: Kaiser Permanente Commercial	$1,259.37
Rate for Payer: Kaiser Permanente Medicaid	$1,019.49
Rate for Payer: Kaiser Permanente Medicare	$472.27
Rate for Payer: MDX Hawaii PPO	$1,939.03
Rate for Payer: Ohana Health Plan Medicaid	$519.50
Rate for Payer: Ohana Health Plan Medicare	$472.27
Rate for Payer: UnitedHealthcare Medicaid	$59.03
Rate for Payer: UnitedHealthcare Medicare	$472.27
Rate for Payer: University Health Alliance Commercial	$201.37

HC RENAL FUNCTION STUDY - NM KIDNEY GFR

Facility

$1,999.00

Service Code	HCPCS 78725
Hospital Charge Code	3417872501
Hospital Revenue Code	341
Min. Negotiated Rate	$1,699.15
Max. Negotiated Rate	$1,939.03
Rate for Payer: Cash Price	$1,199.40
Rate for Payer: Health Management Network Commercial	$1,699.15
Rate for Payer: MDX Hawaii PPO	$1,939.03

HC REPAIR, COMPLEX, EYELIDS, NOSE, EARS, LIPS; EACH ADDITIONAL 5 CM OR LESS

Facility

$785.00

Service Code	HCPCS 13153
Hospital Charge Code	4501315301
Hospital Revenue Code	450
Min. Negotiated Rate	$494.55
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$471.00
Rate for Payer: Cash Price	$471.00
Rate for Payer: Cash Price	$471.00
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 Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$745.75
Rate for Payer: Health Management Network Commercial	$667.25
Rate for Payer: Kaiser Permanente Commercial	$494.55
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$761.45
Rate for Payer: University Health Alliance Commercial	$572.19

HC REPAIR, COMPLEX, EYELIDS, NOSE, EARS, LIPS; EACH ADDITIONAL 5 CM OR LESS

Facility

$785.00

Service Code	HCPCS 13153
Hospital Charge Code	4501315301
Hospital Revenue Code	450
Min. Negotiated Rate	$667.25
Max. Negotiated Rate	$761.45
Rate for Payer: Cash Price	$471.00
Rate for Payer: Health Management Network Commercial	$667.25
Rate for Payer: MDX Hawaii PPO	$761.45

HC REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM

Facility

$2,436.00

Service Code	HCPCS 13120
Hospital Charge Code	4501312001
Hospital Revenue Code	450
Min. Negotiated Rate	$480.23
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
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	$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	$2,314.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: MDX Hawaii PPO	$2,362.92
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	$1,775.60

HC REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM

Facility

$2,436.00

Service Code	HCPCS 13120
Hospital Charge Code	4501312001
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 REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM

Facility

$2,385.00

Service Code	HCPCS 13100
Hospital Charge Code	4501310001
Hospital Revenue Code	450
Min. Negotiated Rate	$520.00
Max. Negotiated Rate	$2,313.45
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Cash Price	$1,431.00
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	$2,265.75
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Commercial	$1,502.55
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: MDX Hawaii PPO	$2,313.45
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	$1,738.43

HC REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM

Facility

$2,385.00

Service Code	HCPCS 13100
Hospital Charge Code	4501310001
Hospital Revenue Code	450
Min. Negotiated Rate	$2,027.25
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: MDX Hawaii PPO	$2,313.45

HC REPAIR LIP,<1/2 VERT HEIGHT

Facility

$2,027.00

Service Code	HCPCS 40652
Hospital Charge Code	7614065201
Hospital Revenue Code	450
Min. Negotiated Rate	$637.13
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$637.13
Rate for Payer: AlohaCare Medicare	$637.13
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Devoted Health Medicare	$700.84
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	$637.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Hawaii Western Management Group Commercial	$1,925.65
Rate for Payer: Health Management Network Commercial	$1,722.95
Rate for Payer: Humana Medicare	$637.13
Rate for Payer: Kaiser Permanente Commercial	$1,277.01
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$637.13
Rate for Payer: MDX Hawaii PPO	$1,966.19
Rate for Payer: Ohana Health Plan Medicaid	$700.84
Rate for Payer: Ohana Health Plan Medicare	$637.13
Rate for Payer: UnitedHealthcare Medicare	$637.13
Rate for Payer: University Health Alliance Commercial	$1,477.48

HC REPAIR LIP,<1/2 VERT HEIGHT

Facility

$2,027.00

Service Code	HCPCS 40652
Hospital Charge Code	7614065201
Hospital Revenue Code	450
Min. Negotiated Rate	$1,722.95
Max. Negotiated Rate	$1,966.19
Rate for Payer: Cash Price	$1,216.20
Rate for Payer: Health Management Network Commercial	$1,722.95
Rate for Payer: MDX Hawaii PPO	$1,966.19

Know your out-of-pocket cost for care.

All Charges