Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

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	$450.00
Max. Negotiated Rate	$2,362.92
Rate for Payer: AlohaCare Medicaid	$1,218.00
Rate for Payer: AlohaCare Medicare	$1,851.36
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$2,046.24
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,851.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
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	$1,851.36
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,851.36
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$1,851.36
Rate for Payer: Ohana Health Plan Medicare	$1,851.36
Rate for Payer: UnitedHealthcare Medicare	$1,851.36
Rate for Payer: University Health Alliance Commercial	$1,775.60

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: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: MDX Hawaii PPO	$2,362.92

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	$795.00
Rate for Payer: AlohaCare Medicare	$1,208.40
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	$1,335.60
Rate for Payer: Hawaii Medical Service Association Commercial	$519.15
Rate for Payer: Hawaii Medical Service Association Medicare	$1,208.40
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	$1,208.40
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$810.90
Rate for Payer: Kaiser Permanente Medicare	$1,208.40
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$1,208.40
Rate for Payer: Ohana Health Plan Medicare	$1,208.40
Rate for Payer: UnitedHealthcare Medicaid	$104.83
Rate for Payer: UnitedHealthcare Medicare	$1,208.40
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: Kaiser Permanente Commercial	$1,431.00
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: Kaiser Permanente Commercial	$1,431.00
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	$450.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$795.00
Rate for Payer: AlohaCare Medicare	$1,208.40
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$1,335.60
Rate for Payer: Hawaii Medical Service Association ABD	$469.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,208.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
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	$1,208.40
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,208.40
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$1,208.40
Rate for Payer: Ohana Health Plan Medicare	$1,208.40
Rate for Payer: UnitedHealthcare Medicare	$1,208.40
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC LIPID PANEL - BUNDLED CHARGE

Facility

$112.00

Service Code	HCPCS 80061
Hospital Charge Code	3018006101
Hospital Revenue Code	301
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: MDX Hawaii PPO	$108.64

HC LIPID PANEL - BUNDLED CHARGE

Facility

$112.00

Service Code	HCPCS 80061
Hospital Charge Code	3018006101
Hospital Revenue Code	301
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$108.64
Rate for Payer: AlohaCare Medicaid	$56.00
Rate for Payer: AlohaCare Medicare	$85.12
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Devoted Health Medicare	$94.08
Rate for Payer: Hawaii Medical Service Association ABD	$18.51
Rate for Payer: Hawaii Medical Service Association Commercial	$16.74
Rate for Payer: Hawaii Medical Service Association Medicare	$85.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.44
Rate for Payer: Hawaii Western Management Group Commercial	$13.39
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: Humana Medicare	$85.12
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$85.12
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$85.12
Rate for Payer: Ohana Health Plan Medicare	$85.12
Rate for Payer: UnitedHealthcare Medicaid	$18.51
Rate for Payer: UnitedHealthcare Medicare	$85.12
Rate for Payer: University Health Alliance Commercial	$34.63

HC MEAS,POST-VOID RES,US,NON-IMAGING

Facility

$236.00

Service Code	HCPCS 51798
Hospital Charge Code	7615179801
Hospital Revenue Code	761
Min. Negotiated Rate	$200.60
Max. Negotiated Rate	$228.92
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: MDX Hawaii PPO	$228.92

HC MEAS,POST-VOID RES,US,NON-IMAGING

Facility

$236.00

Service Code	HCPCS 51798
Hospital Charge Code	7615179801
Hospital Revenue Code	761
Min. Negotiated Rate	$15.83
Max. Negotiated Rate	$228.92
Rate for Payer: AlohaCare Medicaid	$118.00
Rate for Payer: AlohaCare Medicare	$179.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Devoted Health Medicare	$198.24
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$179.36
Rate for Payer: Hawaii Western Management Group Commercial	$224.20
Rate for Payer: Health Management Network Commercial	$200.60
Rate for Payer: Humana Medicare	$179.36
Rate for Payer: Kaiser Permanente Commercial	$212.40
Rate for Payer: Kaiser Permanente Medicaid	$120.36
Rate for Payer: Kaiser Permanente Medicare	$179.36
Rate for Payer: MDX Hawaii PPO	$228.92
Rate for Payer: Ohana Health Plan Medicaid	$179.36
Rate for Payer: Ohana Health Plan Medicare	$179.36
Rate for Payer: UnitedHealthcare Medicaid	$15.83
Rate for Payer: UnitedHealthcare Medicare	$179.36
Rate for Payer: University Health Alliance Commercial	$172.02

HC METABOLIC PANEL,COMPREHENSIVE - BUNDLED CHARGE

Facility

$89.00

Service Code	HCPCS 80053
Hospital Charge Code	3018005301
Hospital Revenue Code	301
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$53.40
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

HC METABOLIC PANEL,COMPREHENSIVE - BUNDLED CHARGE

Facility

$89.00

Service Code	HCPCS 80053
Hospital Charge Code	3018005301
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$67.64
Rate for Payer: Cash Price	$53.40
Rate for Payer: Cash Price	$53.40
Rate for Payer: Devoted Health Medicare	$74.76
Rate for Payer: Hawaii Medical Service Association ABD	$14.61
Rate for Payer: Hawaii Medical Service Association Commercial	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$67.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.34
Rate for Payer: Hawaii Western Management Group Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$67.64
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$67.64
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$67.64
Rate for Payer: Ohana Health Plan Medicare	$67.64
Rate for Payer: UnitedHealthcare Medicaid	$14.61
Rate for Payer: UnitedHealthcare Medicare	$67.64
Rate for Payer: University Health Alliance Commercial	$27.32

HC METABOLIC PANEL,COMPREHENSIVE - POCT

Facility

$89.00

Service Code	HCPCS 80053
Hospital Charge Code	3018005302
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$86.33
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$67.64
Rate for Payer: Cash Price	$53.40
Rate for Payer: Cash Price	$53.40
Rate for Payer: Devoted Health Medicare	$74.76
Rate for Payer: Hawaii Medical Service Association ABD	$14.61
Rate for Payer: Hawaii Medical Service Association Commercial	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$67.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.34
Rate for Payer: Hawaii Western Management Group Commercial	$10.56
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$67.64
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$67.64
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$67.64
Rate for Payer: Ohana Health Plan Medicare	$67.64
Rate for Payer: UnitedHealthcare Medicaid	$14.61
Rate for Payer: UnitedHealthcare Medicare	$67.64
Rate for Payer: University Health Alliance Commercial	$27.32

HC METABOLIC PANEL,COMPREHENSIVE - POCT

Facility

$89.00

Service Code	HCPCS 80053
Hospital Charge Code	3018005302
Hospital Revenue Code	301
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$53.40
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN RANDOM URINE

Facility

$48.00

Service Code	HCPCS 82043
Hospital Charge Code	3018204302
Hospital Revenue Code	301
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$46.56
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: MDX Hawaii PPO	$46.56

HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN RANDOM URINE

Facility

$48.00

Service Code	HCPCS 82043
Hospital Charge Code	3018204302
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$46.56
Rate for Payer: AlohaCare Medicaid	$24.00
Rate for Payer: AlohaCare Medicare	$36.48
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Hawaii Medical Service Association ABD	$8.00
Rate for Payer: Hawaii Medical Service Association Commercial	$7.22
Rate for Payer: Hawaii Medical Service Association Medicare	$36.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.40
Rate for Payer: Hawaii Western Management Group Commercial	$5.78
Rate for Payer: Health Management Network Commercial	$40.80
Rate for Payer: Humana Medicare	$36.48
Rate for Payer: Kaiser Permanente Commercial	$43.20
Rate for Payer: Kaiser Permanente Medicaid	$24.48
Rate for Payer: Kaiser Permanente Medicare	$36.48
Rate for Payer: MDX Hawaii PPO	$46.56
Rate for Payer: Ohana Health Plan Medicaid	$36.48
Rate for Payer: Ohana Health Plan Medicare	$36.48
Rate for Payer: UnitedHealthcare Medicaid	$8.00
Rate for Payer: UnitedHealthcare Medicare	$36.48
Rate for Payer: University Health Alliance Commercial	$14.97

HC MICROBIOTA FECAL PREP

Facility

$3,390.00

Service Code	HCPCS G0455
Hospital Charge Code	750G045501
Hospital Revenue Code	750
Min. Negotiated Rate	$32.30
Max. Negotiated Rate	$3,288.30
Rate for Payer: AlohaCare Medicaid	$1,695.00
Rate for Payer: AlohaCare Medicare	$2,576.40
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Devoted Health Medicare	$2,847.60
Rate for Payer: Hawaii Medical Service Association Commercial	$1,187.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2,576.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.50
Rate for Payer: Health Management Network Commercial	$2,881.50
Rate for Payer: Humana Medicare	$2,576.40
Rate for Payer: Kaiser Permanente Commercial	$3,051.00
Rate for Payer: Kaiser Permanente Medicaid	$1,728.90
Rate for Payer: Kaiser Permanente Medicare	$2,576.40
Rate for Payer: MDX Hawaii PPO	$3,288.30
Rate for Payer: Ohana Health Plan Medicaid	$2,576.40
Rate for Payer: Ohana Health Plan Medicare	$2,576.40
Rate for Payer: UnitedHealthcare Medicaid	$32.30
Rate for Payer: UnitedHealthcare Medicare	$2,576.40
Rate for Payer: University Health Alliance Commercial	$2,470.97

HC MICROBIOTA FECAL PREP

Facility

$3,390.00

Service Code	HCPCS G0455
Hospital Charge Code	750G045501
Hospital Revenue Code	750
Min. Negotiated Rate	$2,881.50
Max. Negotiated Rate	$3,288.30
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Health Management Network Commercial	$2,881.50
Rate for Payer: Kaiser Permanente Commercial	$3,051.00
Rate for Payer: MDX Hawaii PPO	$3,288.30

HC MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS

Facility

$158.00

Service Code	HCPCS 99157
Hospital Charge Code	3709915701
Hospital Revenue Code	370
Min. Negotiated Rate	$58.96
Max. Negotiated Rate	$153.26
Rate for Payer: AlohaCare Medicaid	$79.00
Rate for Payer: AlohaCare Medicare	$120.08
Rate for Payer: Cash Price	$94.80
Rate for Payer: Cash Price	$94.80
Rate for Payer: Devoted Health Medicare	$132.72
Rate for Payer: Hawaii Medical Service Association Medicare	$120.08
Rate for Payer: Hawaii Western Management Group Commercial	$150.10
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Humana Medicare	$120.08
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: Kaiser Permanente Medicare	$120.08
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: Ohana Health Plan Medicaid	$120.08
Rate for Payer: Ohana Health Plan Medicare	$120.08
Rate for Payer: UnitedHealthcare Medicaid	$58.96
Rate for Payer: UnitedHealthcare Medicare	$120.08
Rate for Payer: University Health Alliance Commercial	$115.17

HC MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS

Facility

$158.00

Service Code	HCPCS 99157
Hospital Charge Code	3709915701
Hospital Revenue Code	370
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$94.80
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: MDX Hawaii PPO	$153.26

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS

Facility

$288.00

Service Code	HCPCS 99155
Hospital Charge Code	3709915501
Hospital Revenue Code	370
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: MDX Hawaii PPO	$279.36

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS

Facility

$288.00

Service Code	HCPCS 99155
Hospital Charge Code	3709915501
Hospital Revenue Code	370
Min. Negotiated Rate	$59.68
Max. Negotiated Rate	$279.36
Rate for Payer: AlohaCare Medicaid	$144.00
Rate for Payer: AlohaCare Medicare	$218.88
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Devoted Health Medicare	$241.92
Rate for Payer: Hawaii Medical Service Association Medicare	$218.88
Rate for Payer: Hawaii Western Management Group Commercial	$273.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Humana Medicare	$218.88
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: Kaiser Permanente Medicare	$218.88
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: Ohana Health Plan Medicaid	$218.88
Rate for Payer: Ohana Health Plan Medicare	$218.88
Rate for Payer: UnitedHealthcare Medicaid	$59.68
Rate for Payer: UnitedHealthcare Medicare	$218.88
Rate for Payer: University Health Alliance Commercial	$209.92

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

Facility

$279.00

Service Code	HCPCS 99156
Hospital Charge Code	3709915601
Hospital Revenue Code	370
Min. Negotiated Rate	$53.37
Max. Negotiated Rate	$270.63
Rate for Payer: AlohaCare Medicaid	$139.50
Rate for Payer: AlohaCare Medicare	$212.04
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cash Price	$167.40
Rate for Payer: Devoted Health Medicare	$234.36
Rate for Payer: Hawaii Medical Service Association Medicare	$212.04
Rate for Payer: Hawaii Western Management Group Commercial	$265.05
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: Humana Medicare	$212.04
Rate for Payer: Kaiser Permanente Commercial	$251.10
Rate for Payer: Kaiser Permanente Medicaid	$142.29
Rate for Payer: Kaiser Permanente Medicare	$212.04
Rate for Payer: MDX Hawaii PPO	$270.63
Rate for Payer: Ohana Health Plan Medicaid	$212.04
Rate for Payer: Ohana Health Plan Medicare	$212.04
Rate for Payer: UnitedHealthcare Medicaid	$53.37
Rate for Payer: UnitedHealthcare Medicare	$212.04
Rate for Payer: University Health Alliance Commercial	$203.36

HC MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS

Facility

$279.00

Service Code	HCPCS 99156
Hospital Charge Code	3709915601
Hospital Revenue Code	370
Min. Negotiated Rate	$237.15
Max. Negotiated Rate	$270.63
Rate for Payer: Cash Price	$167.40
Rate for Payer: Health Management Network Commercial	$237.15
Rate for Payer: Kaiser Permanente Commercial	$251.10
Rate for Payer: MDX Hawaii PPO	$270.63

HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS

Facility

$83.00

Service Code	HCPCS 99153
Hospital Charge Code	3709915301
Hospital Revenue Code	370
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$80.51
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$74.70
Rate for Payer: MDX Hawaii PPO	$80.51

Know your out-of-pocket cost for care.

All Charges