Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

insulin glargine 100 units/mL soln [KMC]

Facility

$136.10

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$115.69
Max. Negotiated Rate	$132.02
Rate for Payer: Cash Price	$88.46
Rate for Payer: Health Management Network Commercial	$115.69
Rate for Payer: Kaiser Permanente Commercial	$122.49
Rate for Payer: MDX Hawaii PPO	$132.02

insulin glargine 300 units/mL Soln [KMC]

Facility

$435.38

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$422.32
Rate for Payer: AlohaCare Medicaid	$217.69
Rate for Payer: AlohaCare Medicare	$182.86
Rate for Payer: Cash Price	$283.00
Rate for Payer: Cash Price	$283.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$400.55
Rate for Payer: Devoted Health Medicare	$182.86
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$182.86
Rate for Payer: Hawaii Western Management Group Commercial	$413.61
Rate for Payer: Health Management Network Commercial	$370.07
Rate for Payer: Humana Medicare	$182.86
Rate for Payer: Kaiser Permanente Commercial	$391.84
Rate for Payer: Kaiser Permanente Medicaid	$222.04
Rate for Payer: Kaiser Permanente Medicare	$182.86
Rate for Payer: MDX Hawaii PPO	$422.32
Rate for Payer: Ohana Health Plan Medicaid	$182.86
Rate for Payer: Ohana Health Plan Medicare	$182.86
Rate for Payer: UnitedHealthcare Medicaid	$261.23
Rate for Payer: UnitedHealthcare Medicare	$182.86
Rate for Payer: University Health Alliance Commercial	$317.35

insulin glargine 300 units/mL Soln [KMC]

Facility

$435.38

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$370.07
Max. Negotiated Rate	$422.32
Rate for Payer: Cash Price	$283.00
Rate for Payer: Health Management Network Commercial	$370.07
Rate for Payer: Kaiser Permanente Commercial	$391.84
Rate for Payer: MDX Hawaii PPO	$422.32

insulin lispro 200 units/mL Soln [KMC]

Facility

$339.45

Service Code	HCPCS J1817
Hospital Revenue Code	636
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$329.27
Rate for Payer: AlohaCare Medicaid	$169.72
Rate for Payer: AlohaCare Medicare	$142.57
Rate for Payer: Cash Price	$220.64
Rate for Payer: Cash Price	$220.64
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$312.29
Rate for Payer: Devoted Health Medicare	$142.57
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$3.24
Rate for Payer: Hawaii Medical Service Association Medicare	$142.57
Rate for Payer: Hawaii Western Management Group Commercial	$322.48
Rate for Payer: Health Management Network Commercial	$288.53
Rate for Payer: Humana Medicare	$142.57
Rate for Payer: Kaiser Permanente Commercial	$305.50
Rate for Payer: Kaiser Permanente Medicaid	$173.12
Rate for Payer: Kaiser Permanente Medicare	$142.57
Rate for Payer: MDX Hawaii PPO	$329.27
Rate for Payer: Ohana Health Plan Medicaid	$142.57
Rate for Payer: Ohana Health Plan Medicare	$142.57
Rate for Payer: UnitedHealthcare Medicaid	$203.67
Rate for Payer: UnitedHealthcare Medicare	$142.57
Rate for Payer: University Health Alliance Commercial	$247.43

insulin lispro 200 units/mL Soln [KMC]

Facility

$339.45

Service Code	HCPCS J1817
Hospital Revenue Code	636
Min. Negotiated Rate	$288.53
Max. Negotiated Rate	$329.27
Rate for Payer: Cash Price	$220.64
Rate for Payer: Health Management Network Commercial	$288.53
Rate for Payer: Kaiser Permanente Commercial	$305.50
Rate for Payer: MDX Hawaii PPO	$329.27

insulin lispro/lispro protamine 25 / 75 units/mL susp [KMC]

Facility

$86.75

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$73.74
Max. Negotiated Rate	$84.15
Rate for Payer: Cash Price	$56.39
Rate for Payer: Health Management Network Commercial	$73.74
Rate for Payer: Kaiser Permanente Commercial	$78.08
Rate for Payer: MDX Hawaii PPO	$84.15

insulin lispro/lispro protamine 25 / 75 units/mL susp [KMC]

Facility

$86.75

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$84.15
Rate for Payer: AlohaCare Medicaid	$43.38
Rate for Payer: AlohaCare Medicare	$36.44
Rate for Payer: Cash Price	$56.39
Rate for Payer: Cash Price	$56.39
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$79.81
Rate for Payer: Devoted Health Medicare	$36.44
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$36.44
Rate for Payer: Hawaii Western Management Group Commercial	$82.41
Rate for Payer: Health Management Network Commercial	$73.74
Rate for Payer: Humana Medicare	$36.44
Rate for Payer: Kaiser Permanente Commercial	$78.08
Rate for Payer: Kaiser Permanente Medicaid	$44.24
Rate for Payer: Kaiser Permanente Medicare	$36.44
Rate for Payer: MDX Hawaii PPO	$84.15
Rate for Payer: Ohana Health Plan Medicaid	$36.44
Rate for Payer: Ohana Health Plan Medicare	$36.44
Rate for Payer: UnitedHealthcare Medicaid	$52.05
Rate for Payer: UnitedHealthcare Medicare	$36.44
Rate for Payer: University Health Alliance Commercial	$63.23

insulin NPH (Novolin FlexPen) 100 units/mL Susp [KMC]

Facility

$83.28

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$80.78
Rate for Payer: AlohaCare Medicaid	$41.64
Rate for Payer: AlohaCare Medicare	$34.98
Rate for Payer: Cash Price	$54.13
Rate for Payer: Cash Price	$54.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$76.62
Rate for Payer: Devoted Health Medicare	$34.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$34.98
Rate for Payer: Hawaii Western Management Group Commercial	$79.12
Rate for Payer: Health Management Network Commercial	$70.79
Rate for Payer: Humana Medicare	$34.98
Rate for Payer: Kaiser Permanente Commercial	$74.95
Rate for Payer: Kaiser Permanente Medicaid	$42.47
Rate for Payer: Kaiser Permanente Medicare	$34.98
Rate for Payer: MDX Hawaii PPO	$80.78
Rate for Payer: Ohana Health Plan Medicaid	$34.98
Rate for Payer: Ohana Health Plan Medicare	$34.98
Rate for Payer: UnitedHealthcare Medicaid	$49.97
Rate for Payer: UnitedHealthcare Medicare	$34.98
Rate for Payer: University Health Alliance Commercial	$60.70

insulin NPH (Novolin FlexPen) 100 units/mL Susp [KMC]

Facility

$83.28

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$70.79
Max. Negotiated Rate	$80.78
Rate for Payer: Cash Price	$54.13
Rate for Payer: Health Management Network Commercial	$70.79
Rate for Payer: Kaiser Permanente Commercial	$74.95
Rate for Payer: MDX Hawaii PPO	$80.78

insulin regular 100 units/mL soln [KMC]

Facility

$71.37

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$69.23
Rate for Payer: AlohaCare Medicaid	$35.69
Rate for Payer: AlohaCare Medicare	$29.98
Rate for Payer: Cash Price	$46.39
Rate for Payer: Cash Price	$46.39
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$65.66
Rate for Payer: Devoted Health Medicare	$29.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$0.90
Rate for Payer: Hawaii Medical Service Association Medicare	$29.98
Rate for Payer: Hawaii Western Management Group Commercial	$67.80
Rate for Payer: Health Management Network Commercial	$60.66
Rate for Payer: Humana Medicare	$29.98
Rate for Payer: Kaiser Permanente Commercial	$64.23
Rate for Payer: Kaiser Permanente Medicaid	$36.40
Rate for Payer: Kaiser Permanente Medicare	$29.98
Rate for Payer: MDX Hawaii PPO	$69.23
Rate for Payer: Ohana Health Plan Medicaid	$29.98
Rate for Payer: Ohana Health Plan Medicare	$29.98
Rate for Payer: UnitedHealthcare Medicaid	$42.82
Rate for Payer: UnitedHealthcare Medicare	$29.98
Rate for Payer: University Health Alliance Commercial	$52.02

insulin regular 100 units/mL soln [KMC]

Facility

$71.37

Service Code	HCPCS J1815
Hospital Revenue Code	636
Min. Negotiated Rate	$60.66
Max. Negotiated Rate	$69.23
Rate for Payer: Cash Price	$46.39
Rate for Payer: Health Management Network Commercial	$60.66
Rate for Payer: Kaiser Permanente Commercial	$64.23
Rate for Payer: MDX Hawaii PPO	$69.23

INTERMEDIATE REPAIR, 2.6-7.5CM CHARGE

Facility

$1,017.00

Service Code	HCPCS 12042
Hospital Charge Code	440120420
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$741.29

INTERMEDIATE REPAIR, 2.6-7.5CM CHARGE

Facility

$1,017.00

Service Code	HCPCS 12042
Hospital Charge Code	440120420
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

INTERMEDIATE WOUND REPAIR CHARGE

Facility

$1,017.00

Service Code	HCPCS 12032
Hospital Charge Code	440120320
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$4,035.20

INTERMEDIATE WOUND REPAIR CHARGE

Facility

$1,017.00

Service Code	HCPCS 12032
Hospital Charge Code	440120320
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

INTERMED LAC 12.6-20 CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12045
Hospital Charge Code	440120450
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

INTERMED LAC 12.6-20 CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12045
Hospital Charge Code	440120450
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$741.29

INTERMED LAC 12.6-20 CM ED Charge

Facility

$2,091.00

Service Code	HCPCS 12035
Hospital Charge Code	440120350
Hospital Revenue Code	450
Min. Negotiated Rate	$1,777.35
Max. Negotiated Rate	$2,028.27
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: MDX Hawaii PPO	$2,028.27

INTERMED LAC 12.6-20 CM ED Charge

Facility

$2,091.00

Service Code	HCPCS 12035
Hospital Charge Code	440120350
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$1,045.50
Rate for Payer: AlohaCare Medicare	$878.22
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Cash Price	$1,359.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,923.72
Rate for Payer: Devoted Health Medicare	$878.22
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$878.22
Rate for Payer: Hawaii Western Management Group Commercial	$1,986.45
Rate for Payer: Health Management Network Commercial	$1,777.35
Rate for Payer: Humana Medicare	$878.22
Rate for Payer: Kaiser Permanente Commercial	$1,881.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$878.22
Rate for Payer: MDX Hawaii PPO	$2,028.27
Rate for Payer: Ohana Health Plan Medicaid	$878.22
Rate for Payer: Ohana Health Plan Medicare	$878.22
Rate for Payer: UnitedHealthcare Medicare	$878.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

INTERMED LAC 20.1-30CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12046
Hospital Charge Code	440120460
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$741.29

INTERMED LAC 20.1-30CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12046
Hospital Charge Code	440120460
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

INTERMED LAC FACE <2.5 CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12051
Hospital Charge Code	440120510
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$508.50
Rate for Payer: AlohaCare Medicare	$427.14
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Cash Price	$661.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$935.64
Rate for Payer: Devoted Health Medicare	$427.14
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$427.14
Rate for Payer: Hawaii Western Management Group Commercial	$966.15
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Humana Medicare	$427.14
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$427.14
Rate for Payer: MDX Hawaii PPO	$986.49
Rate for Payer: Ohana Health Plan Medicaid	$427.14
Rate for Payer: Ohana Health Plan Medicare	$427.14
Rate for Payer: UnitedHealthcare Medicare	$427.14
Rate for Payer: University Health Alliance Commercial	$4,035.20

INTERMED LAC FACE <2.5 CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12051
Hospital Charge Code	440120510
Hospital Revenue Code	450
Min. Negotiated Rate	$864.45
Max. Negotiated Rate	$986.49
Rate for Payer: Cash Price	$661.05
Rate for Payer: Health Management Network Commercial	$864.45
Rate for Payer: Kaiser Permanente Commercial	$915.30
Rate for Payer: MDX Hawaii PPO	$986.49

INTERMED LAC FACE 2.6-5CM ED Charge

Facility

$1,179.00

Service Code	HCPCS 12052
Hospital Charge Code	440120520
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$589.50
Rate for Payer: AlohaCare Medicare	$495.18
Rate for Payer: Cash Price	$766.35
Rate for Payer: Cash Price	$766.35
Rate for Payer: Cash Price	$766.35
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,084.68
Rate for Payer: Devoted Health Medicare	$495.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$495.18
Rate for Payer: Hawaii Western Management Group Commercial	$1,120.05
Rate for Payer: Health Management Network Commercial	$1,002.15
Rate for Payer: Humana Medicare	$495.18
Rate for Payer: Kaiser Permanente Commercial	$1,061.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$495.18
Rate for Payer: MDX Hawaii PPO	$1,143.63
Rate for Payer: Ohana Health Plan Medicaid	$495.18
Rate for Payer: Ohana Health Plan Medicare	$495.18
Rate for Payer: UnitedHealthcare Medicare	$495.18
Rate for Payer: University Health Alliance Commercial	$859.37

INTERMED LAC FACE 2.6-5CM ED Charge

Facility

$1,179.00

Service Code	HCPCS 12052
Hospital Charge Code	440120520
Hospital Revenue Code	450
Min. Negotiated Rate	$1,002.15
Max. Negotiated Rate	$1,143.63
Rate for Payer: Cash Price	$766.35
Rate for Payer: Health Management Network Commercial	$1,002.15
Rate for Payer: Kaiser Permanente Commercial	$1,061.10
Rate for Payer: MDX Hawaii PPO	$1,143.63

Know your out-of-pocket cost for care.

All Charges