Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC RESUPERF WND FACE <2.5 CM

Facility

$791.00

Service Code	HCPCS 12011
Hospital Charge Code	4501201101
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND FACE <2.5 CM

Facility

$791.00

Service Code	HCPCS 12011
Hospital Charge Code	4501201101
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUPERF WND FACE 2.6-5 CM

Facility

$791.00

Service Code	HCPCS 12013
Hospital Charge Code	4501201301
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUPERF WND FACE 2.6-5 CM

Facility

$791.00

Service Code	HCPCS 12013
Hospital Charge Code	4501201301
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND FACE 5.1-7.5 CM

Facility

$791.00

Service Code	HCPCS 12014
Hospital Charge Code	4501201401
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND FACE 5.1-7.5 CM

Facility

$791.00

Service Code	HCPCS 12014
Hospital Charge Code	4501201401
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUPERF WND FACE 7.6-12.5 CM

Facility

$791.00

Service Code	HCPCS 12015
Hospital Charge Code	4501201501
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RESUPERF WND FACE 7.6-12.5 CM

Facility

$791.00

Service Code	HCPCS 12015
Hospital Charge Code	4501201501
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUP NPTERF WND BODY 2.6-7.5 CM

Facility

$791.00

Service Code	HCPCS 12002
Hospital Charge Code	4501200201
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Cash Price	$474.60
Rate for Payer: Devoted Health Medicare	$260.72
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	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$751.45
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$498.33
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$767.27
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$576.56

HC RESUP NPTERF WND BODY 2.6-7.5 CM

Facility

$791.00

Service Code	HCPCS 12002
Hospital Charge Code	4501200201
Hospital Revenue Code	450
Min. Negotiated Rate	$672.35
Max. Negotiated Rate	$767.27
Rate for Payer: Cash Price	$474.60
Rate for Payer: Health Management Network Commercial	$672.35
Rate for Payer: MDX Hawaii PPO	$767.27

HC RETICULOCYTE COUNT, AUTO - RETICULOCYTES

Facility

$33.00

Service Code	HCPCS 85045
Hospital Charge Code	3058504501
Hospital Revenue Code	305
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

HC RETICULOCYTE COUNT, AUTO - RETICULOCYTES

Facility

$33.00

Service Code	HCPCS 85045
Hospital Charge Code	3058504501
Hospital Revenue Code	305
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$32.01
Rate for Payer: AlohaCare Medicaid	$3.99
Rate for Payer: AlohaCare Medicare	$3.99
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Devoted Health Medicare	$4.39
Rate for Payer: Hawaii Medical Service Association ABD	$5.59
Rate for Payer: Hawaii Medical Service Association Commercial	$4.99
Rate for Payer: Hawaii Medical Service Association Medicare	$3.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.87
Rate for Payer: Hawaii Western Management Group Commercial	$3.99
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Humana Medicare	$3.99
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$3.99
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: Ohana Health Plan Medicaid	$4.39
Rate for Payer: Ohana Health Plan Medicare	$3.99
Rate for Payer: UnitedHealthcare Medicaid	$5.59
Rate for Payer: UnitedHealthcare Medicare	$3.99
Rate for Payer: University Health Alliance Commercial	$10.34

HC REVASC LITHOTRIP TIBI/PERONE

Facility

$44,191.00

Service Code	HCPCS C9772
Hospital Charge Code	360C977201
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$42,865.27
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association Commercial	$17,047.09
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Health Management Network Commercial	$37,562.35
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Commercial	$27,840.33
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: MDX Hawaii PPO	$42,865.27
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$32,210.82

HC REVASC LITHOTRIP TIBI/PERONE

Facility

$44,191.00

Service Code	HCPCS C9772
Hospital Charge Code	360C977201
Hospital Revenue Code	360
Min. Negotiated Rate	$37,562.35
Max. Negotiated Rate	$42,865.27
Rate for Payer: Cash Price	$26,514.60
Rate for Payer: Health Management Network Commercial	$37,562.35
Rate for Payer: MDX Hawaii PPO	$42,865.27

HC REV EVAR LE AA IV LITHO&ATHREC

Facility

$89,326.00

Service Code	HCPCS C9766
Hospital Charge Code	481C976601
Hospital Revenue Code	481
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$86,646.22
Rate for Payer: AlohaCare Medicaid	$21,655.98
Rate for Payer: AlohaCare Medicare	$21,655.98
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Devoted Health Medicare	$23,821.58
Rate for Payer: Hawaii Medical Service Association Commercial	$27,069.97
Rate for Payer: Hawaii Medical Service Association Medicare	$21,655.98
Rate for Payer: Hawaii Western Management Group Commercial	$84,859.70
Rate for Payer: Health Management Network Commercial	$75,927.10
Rate for Payer: Humana Medicare	$21,655.98
Rate for Payer: Kaiser Permanente Commercial	$56,275.38
Rate for Payer: Kaiser Permanente Medicaid	$45,556.26
Rate for Payer: Kaiser Permanente Medicare	$21,655.98
Rate for Payer: MDX Hawaii PPO	$86,646.22
Rate for Payer: Ohana Health Plan Medicaid	$23,821.58
Rate for Payer: Ohana Health Plan Medicare	$21,655.98
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$21,655.98
Rate for Payer: University Health Alliance Commercial	$65,109.72

HC REV EVAR LE AA IV LITHO&ATHREC

Facility

$89,326.00

Service Code	HCPCS C9766
Hospital Charge Code	481C976601
Hospital Revenue Code	481
Min. Negotiated Rate	$75,927.10
Max. Negotiated Rate	$86,646.22
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Health Management Network Commercial	$75,927.10
Rate for Payer: MDX Hawaii PPO	$86,646.22

HC REV EVAR OPEN/PERQ LE AA IV LI

Facility

$56,414.00

Service Code	HCPCS C9764
Hospital Charge Code	360C976401
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$54,721.58
Rate for Payer: AlohaCare Medicaid	$13,637.67
Rate for Payer: AlohaCare Medicare	$13,637.67
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Devoted Health Medicare	$15,001.44
Rate for Payer: Hawaii Medical Service Association Commercial	$17,047.09
Rate for Payer: Hawaii Medical Service Association Medicare	$13,637.67
Rate for Payer: Health Management Network Commercial	$47,951.90
Rate for Payer: Humana Medicare	$13,637.67
Rate for Payer: Kaiser Permanente Commercial	$35,540.82
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$13,637.67
Rate for Payer: MDX Hawaii PPO	$54,721.58
Rate for Payer: Ohana Health Plan Medicaid	$15,001.44
Rate for Payer: Ohana Health Plan Medicare	$13,637.67
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$13,637.67
Rate for Payer: University Health Alliance Commercial	$24,500.00

HC REV EVAR OPEN/PERQ LE AA IV LI

Facility

$56,414.00

Service Code	HCPCS C9764
Hospital Charge Code	360C976401
Hospital Revenue Code	360
Min. Negotiated Rate	$47,951.90
Max. Negotiated Rate	$54,721.58
Rate for Payer: Cash Price	$33,848.40
Rate for Payer: Health Management Network Commercial	$47,951.90
Rate for Payer: MDX Hawaii PPO	$54,721.58

HC REV EVR LE AA;IV LITH&TL STNT

Facility

$89,326.00

Service Code	HCPCS C9765
Hospital Charge Code	360C976501
Hospital Revenue Code	360
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$86,646.22
Rate for Payer: AlohaCare Medicaid	$21,655.98
Rate for Payer: AlohaCare Medicare	$21,655.98
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Devoted Health Medicare	$23,821.58
Rate for Payer: Hawaii Medical Service Association Commercial	$27,069.97
Rate for Payer: Hawaii Medical Service Association Medicare	$21,655.98
Rate for Payer: Health Management Network Commercial	$75,927.10
Rate for Payer: Humana Medicare	$21,655.98
Rate for Payer: Kaiser Permanente Commercial	$56,275.38
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$21,655.98
Rate for Payer: MDX Hawaii PPO	$86,646.22
Rate for Payer: Ohana Health Plan Medicaid	$23,821.58
Rate for Payer: Ohana Health Plan Medicare	$21,655.98
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$21,655.98
Rate for Payer: University Health Alliance Commercial	$65,109.72

HC REV EVR LE AA;IV LITH&TL STNT

Facility

$89,326.00

Service Code	HCPCS C9765
Hospital Charge Code	360C976501
Hospital Revenue Code	360
Min. Negotiated Rate	$75,927.10
Max. Negotiated Rate	$86,646.22
Rate for Payer: Cash Price	$53,595.60
Rate for Payer: Health Management Network Commercial	$75,927.10
Rate for Payer: MDX Hawaii PPO	$86,646.22

HC REVIS TRANSVEN INTRAHEP PORTOSYS SHUNT

Facility

$22,690.00

Service Code	HCPCS 37183
Hospital Charge Code	3613718301
Hospital Revenue Code	361
Min. Negotiated Rate	$644.55
Max. Negotiated Rate	$22,009.30
Rate for Payer: AlohaCare Medicaid	$6,723.70
Rate for Payer: AlohaCare Medicare	$6,723.70
Rate for Payer: Cash Price	$13,614.00
Rate for Payer: Cash Price	$13,614.00
Rate for Payer: Cash Price	$13,614.00
Rate for Payer: Devoted Health Medicare	$7,396.07
Rate for Payer: Hawaii Medical Service Association ABD	$2,102.00
Rate for Payer: Hawaii Medical Service Association Commercial	$19,192.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,723.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,561.00
Rate for Payer: Health Management Network Commercial	$19,286.50
Rate for Payer: Humana Medicare	$6,723.70
Rate for Payer: Kaiser Permanente Commercial	$14,294.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,723.70
Rate for Payer: MDX Hawaii PPO	$22,009.30
Rate for Payer: Ohana Health Plan Medicaid	$7,396.07
Rate for Payer: Ohana Health Plan Medicare	$6,723.70
Rate for Payer: UnitedHealthcare Medicaid	$644.55
Rate for Payer: UnitedHealthcare Medicare	$6,723.70
Rate for Payer: University Health Alliance Commercial	$16,538.74

HC REVIS TRANSVEN INTRAHEP PORTOSYS SHUNT

Facility

$22,690.00

Service Code	HCPCS 37183
Hospital Charge Code	3613718301
Hospital Revenue Code	361
Min. Negotiated Rate	$19,286.50
Max. Negotiated Rate	$22,009.30
Rate for Payer: Cash Price	$13,614.00
Rate for Payer: Health Management Network Commercial	$19,286.50
Rate for Payer: MDX Hawaii PPO	$22,009.30

HC REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF

Facility

$21,065.00

Service Code	HCPCS 36832
Hospital Charge Code	3613683201
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$20,433.05
Rate for Payer: AlohaCare Medicaid	$6,573.58
Rate for Payer: AlohaCare Medicare	$6,573.58
Rate for Payer: Cash Price	$12,639.00
Rate for Payer: Cash Price	$12,639.00
Rate for Payer: Cash Price	$12,639.00
Rate for Payer: Devoted Health Medicare	$7,230.94
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	$6,573.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Health Management Network Commercial	$17,905.25
Rate for Payer: Humana Medicare	$6,573.58
Rate for Payer: Kaiser Permanente Commercial	$13,270.95
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,573.58
Rate for Payer: MDX Hawaii PPO	$20,433.05
Rate for Payer: Ohana Health Plan Medicaid	$7,230.94
Rate for Payer: Ohana Health Plan Medicare	$6,573.58
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,573.58
Rate for Payer: University Health Alliance Commercial	$10,679.55

HC REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF

Facility

$21,065.00

Service Code	HCPCS 36832
Hospital Charge Code	3613683201
Hospital Revenue Code	361
Min. Negotiated Rate	$17,905.25
Max. Negotiated Rate	$20,433.05
Rate for Payer: Cash Price	$12,639.00
Rate for Payer: Health Management Network Commercial	$17,905.25
Rate for Payer: MDX Hawaii PPO	$20,433.05

HC REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL

Facility

$19,596.00

Service Code	HCPCS 37265
Hospital Charge Code	4813726501
Hospital Revenue Code	481
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$19,008.12
Rate for Payer: AlohaCare Medicaid	$6,723.70
Rate for Payer: AlohaCare Medicare	$6,723.70
Rate for Payer: Cash Price	$11,757.60
Rate for Payer: Cash Price	$11,757.60
Rate for Payer: Cash Price	$11,757.60
Rate for Payer: Devoted Health Medicare	$7,396.07
Rate for Payer: Hawaii Medical Service Association Commercial	$8,404.62
Rate for Payer: Hawaii Medical Service Association Medicare	$6,723.70
Rate for Payer: Hawaii Western Management Group Commercial	$18,616.20
Rate for Payer: Health Management Network Commercial	$16,656.60
Rate for Payer: Humana Medicare	$6,723.70
Rate for Payer: Kaiser Permanente Commercial	$12,345.48
Rate for Payer: Kaiser Permanente Medicaid	$9,993.96
Rate for Payer: Kaiser Permanente Medicare	$6,723.70
Rate for Payer: MDX Hawaii PPO	$19,008.12
Rate for Payer: Ohana Health Plan Medicaid	$7,396.07
Rate for Payer: Ohana Health Plan Medicare	$6,723.70
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$6,723.70
Rate for Payer: University Health Alliance Commercial	$14,283.52

Know your out-of-pocket cost for care.

All Charges