Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

simethicone 125 mg Chew [KMC]

Facility

$3.00

Service Code	NDC 00067011748
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

simethicone 125 mg Chew [KMC]

Facility

$3.00

Service Code	NDC 00067011748
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

simethicone 80 mg Chew Tab [KMC]

Facility

$3.00

Service Code	NDC 49348018810
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

simethicone 80 mg Chew Tab [KMC]

Facility

$3.00

Service Code	NDC 49348018810
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

SIMPLE LAC 12.6-20 CM ED Charge

Facility

$1,263.00

Service Code	HCPCS 12005
Hospital Charge Code	440120050
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$631.50
Rate for Payer: AlohaCare Medicare	$530.46
Rate for Payer: Cash Price	$820.95
Rate for Payer: Cash Price	$820.95
Rate for Payer: Cash Price	$820.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,161.96
Rate for Payer: Devoted Health Medicare	$530.46
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	$530.46
Rate for Payer: Hawaii Western Management Group Commercial	$1,199.85
Rate for Payer: Health Management Network Commercial	$1,073.55
Rate for Payer: Humana Medicare	$530.46
Rate for Payer: Kaiser Permanente Commercial	$1,136.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$530.46
Rate for Payer: MDX Hawaii PPO	$1,225.11
Rate for Payer: Ohana Health Plan Medicaid	$530.46
Rate for Payer: Ohana Health Plan Medicare	$530.46
Rate for Payer: UnitedHealthcare Medicare	$530.46
Rate for Payer: University Health Alliance Commercial	$920.60

SIMPLE LAC 12.6-20 CM ED Charge

Facility

$1,263.00

Service Code	HCPCS 12005
Hospital Charge Code	440120050
Hospital Revenue Code	450
Min. Negotiated Rate	$1,073.55
Max. Negotiated Rate	$1,225.11
Rate for Payer: Cash Price	$820.95
Rate for Payer: Health Management Network Commercial	$1,073.55
Rate for Payer: Kaiser Permanente Commercial	$1,136.70
Rate for Payer: MDX Hawaii PPO	$1,225.11

SIMPLE LAC 20.1-30 CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12006
Hospital Charge Code	440120060
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

SIMPLE LAC 20.1-30 CM ED Charge

Facility

$1,017.00

Service Code	HCPCS 12006
Hospital Charge Code	440120060
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

SIMPLE LAC <2.5CM ED Charge

Facility

$620.00

Service Code	HCPCS 12001
Hospital Charge Code	440120010
Hospital Revenue Code	450
Min. Negotiated Rate	$527.00
Max. Negotiated Rate	$601.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: MDX Hawaii PPO	$601.40

SIMPLE LAC <2.5CM ED Charge

Facility

$620.00

Service Code	HCPCS 12001
Hospital Charge Code	440120010
Hospital Revenue Code	450
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$310.00
Rate for Payer: AlohaCare Medicare	$260.40
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Cash Price	$403.00
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$570.40
Rate for Payer: Devoted Health Medicare	$260.40
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	$260.40
Rate for Payer: Hawaii Western Management Group Commercial	$589.00
Rate for Payer: Health Management Network Commercial	$527.00
Rate for Payer: Humana Medicare	$260.40
Rate for Payer: Kaiser Permanente Commercial	$558.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$260.40
Rate for Payer: MDX Hawaii PPO	$601.40
Rate for Payer: Ohana Health Plan Medicaid	$260.40
Rate for Payer: Ohana Health Plan Medicare	$260.40
Rate for Payer: UnitedHealthcare Medicare	$260.40
Rate for Payer: University Health Alliance Commercial	$451.92

SIMPLE LAC 2.6-7.5 CM ED Charge

Facility

$802.00

Service Code	HCPCS 12002
Hospital Charge Code	440120020
Hospital Revenue Code	450
Min. Negotiated Rate	$681.70
Max. Negotiated Rate	$777.94
Rate for Payer: Cash Price	$521.30
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: MDX Hawaii PPO	$777.94

SIMPLE LAC 2.6-7.5 CM ED Charge

Facility

$802.00

Service Code	HCPCS 12002
Hospital Charge Code	440120020
Hospital Revenue Code	450
Min. Negotiated Rate	$336.84
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$401.00
Rate for Payer: AlohaCare Medicare	$336.84
Rate for Payer: Cash Price	$521.30
Rate for Payer: Cash Price	$521.30
Rate for Payer: Cash Price	$521.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$737.84
Rate for Payer: Devoted Health Medicare	$336.84
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	$336.84
Rate for Payer: Hawaii Western Management Group Commercial	$761.90
Rate for Payer: Health Management Network Commercial	$681.70
Rate for Payer: Humana Medicare	$336.84
Rate for Payer: Kaiser Permanente Commercial	$721.80
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$336.84
Rate for Payer: MDX Hawaii PPO	$777.94
Rate for Payer: Ohana Health Plan Medicaid	$336.84
Rate for Payer: Ohana Health Plan Medicare	$336.84
Rate for Payer: UnitedHealthcare Medicare	$336.84
Rate for Payer: University Health Alliance Commercial	$584.58

SIMPLE LAC 7.6-12.5 CM ED Charge

Facility

$931.00

Service Code	HCPCS 12004
Hospital Charge Code	440120040
Hospital Revenue Code	450
Min. Negotiated Rate	$391.02
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$465.50
Rate for Payer: AlohaCare Medicare	$391.02
Rate for Payer: Cash Price	$605.15
Rate for Payer: Cash Price	$605.15
Rate for Payer: Cash Price	$605.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$856.52
Rate for Payer: Devoted Health Medicare	$391.02
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	$391.02
Rate for Payer: Hawaii Western Management Group Commercial	$884.45
Rate for Payer: Health Management Network Commercial	$791.35
Rate for Payer: Humana Medicare	$391.02
Rate for Payer: Kaiser Permanente Commercial	$837.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$391.02
Rate for Payer: MDX Hawaii PPO	$903.07
Rate for Payer: Ohana Health Plan Medicaid	$391.02
Rate for Payer: Ohana Health Plan Medicare	$391.02
Rate for Payer: UnitedHealthcare Medicare	$391.02
Rate for Payer: University Health Alliance Commercial	$678.61

SIMPLE LAC 7.6-12.5 CM ED Charge

Facility

$931.00

Service Code	HCPCS 12004
Hospital Charge Code	440120040
Hospital Revenue Code	450
Min. Negotiated Rate	$791.35
Max. Negotiated Rate	$903.07
Rate for Payer: Cash Price	$605.15
Rate for Payer: Health Management Network Commercial	$791.35
Rate for Payer: Kaiser Permanente Commercial	$837.90
Rate for Payer: MDX Hawaii PPO	$903.07

SIMPLE LAC FACE 12.6-20CM ED Charge

Facility

$429.00

Service Code	HCPCS 12016
Hospital Charge Code	440120160
Hospital Revenue Code	450
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

SIMPLE LAC FACE 12.6-20CM ED Charge

Facility

$429.00

Service Code	HCPCS 12016
Hospital Charge Code	440120160
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$180.18
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$394.68
Rate for Payer: Devoted Health Medicare	$180.18
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	$180.18
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$180.18
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.18
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$180.18
Rate for Payer: Ohana Health Plan Medicare	$180.18
Rate for Payer: UnitedHealthcare Medicare	$180.18
Rate for Payer: University Health Alliance Commercial	$312.70

SIMPLE LAC FACE 20.1-30CM ED Charge

Facility

$429.00

Service Code	HCPCS 12017
Hospital Charge Code	440120170
Hospital Revenue Code	450
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

SIMPLE LAC FACE 20.1-30CM ED Charge

Facility

$429.00

Service Code	HCPCS 12017
Hospital Charge Code	440120170
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$180.18
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$394.68
Rate for Payer: Devoted Health Medicare	$180.18
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	$180.18
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$180.18
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.18
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$180.18
Rate for Payer: Ohana Health Plan Medicare	$180.18
Rate for Payer: UnitedHealthcare Medicare	$180.18
Rate for Payer: University Health Alliance Commercial	$312.70

SIMPLE LAC FACE 2.6-5 CM ED Charge

Facility

$1,248.00

Service Code	HCPCS 12013
Hospital Charge Code	440120130
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$624.00
Rate for Payer: AlohaCare Medicare	$524.16
Rate for Payer: Cash Price	$811.20
Rate for Payer: Cash Price	$811.20
Rate for Payer: Cash Price	$811.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,148.16
Rate for Payer: Devoted Health Medicare	$524.16
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	$524.16
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.60
Rate for Payer: Health Management Network Commercial	$1,060.80
Rate for Payer: Humana Medicare	$524.16
Rate for Payer: Kaiser Permanente Commercial	$1,123.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$524.16
Rate for Payer: MDX Hawaii PPO	$1,210.56
Rate for Payer: Ohana Health Plan Medicaid	$524.16
Rate for Payer: Ohana Health Plan Medicare	$524.16
Rate for Payer: UnitedHealthcare Medicare	$524.16
Rate for Payer: University Health Alliance Commercial	$909.67

SIMPLE LAC FACE 2.6-5 CM ED Charge

Facility

$1,248.00

Service Code	HCPCS 12013
Hospital Charge Code	440120130
Hospital Revenue Code	450
Min. Negotiated Rate	$1,060.80
Max. Negotiated Rate	$1,210.56
Rate for Payer: Cash Price	$811.20
Rate for Payer: Health Management Network Commercial	$1,060.80
Rate for Payer: Kaiser Permanente Commercial	$1,123.20
Rate for Payer: MDX Hawaii PPO	$1,210.56

SIMPLE LAC FACE >30CM ED Charge

Facility

$429.00

Service Code	HCPCS 12018
Hospital Charge Code	440120180
Hospital Revenue Code	450
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

SIMPLE LAC FACE >30CM ED Charge

Facility

$429.00

Service Code	HCPCS 12018
Hospital Charge Code	440120180
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$180.18
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$394.68
Rate for Payer: Devoted Health Medicare	$180.18
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	$180.18
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$180.18
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.18
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$180.18
Rate for Payer: Ohana Health Plan Medicare	$180.18
Rate for Payer: UnitedHealthcare Medicare	$180.18
Rate for Payer: University Health Alliance Commercial	$312.70

SIMPLE LAC FACE 5.1-7.5CM ED Charge

Facility

$429.00

Service Code	HCPCS 12014
Hospital Charge Code	440120140
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$180.18
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$394.68
Rate for Payer: Devoted Health Medicare	$180.18
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	$180.18
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$180.18
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.18
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$180.18
Rate for Payer: Ohana Health Plan Medicare	$180.18
Rate for Payer: UnitedHealthcare Medicare	$180.18
Rate for Payer: University Health Alliance Commercial	$312.70

SIMPLE LAC FACE 5.1-7.5CM ED Charge

Facility

$429.00

Service Code	HCPCS 12014
Hospital Charge Code	440120140
Hospital Revenue Code	450
Min. Negotiated Rate	$364.65
Max. Negotiated Rate	$416.13
Rate for Payer: Cash Price	$278.85
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: MDX Hawaii PPO	$416.13

SIMPLE LAC FACE 7.6-12.5 ED Charge

Facility

$429.00

Service Code	HCPCS 12015
Hospital Charge Code	440120150
Hospital Revenue Code	450
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$214.50
Rate for Payer: AlohaCare Medicare	$180.18
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Cash Price	$278.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$394.68
Rate for Payer: Devoted Health Medicare	$180.18
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	$180.18
Rate for Payer: Hawaii Western Management Group Commercial	$407.55
Rate for Payer: Health Management Network Commercial	$364.65
Rate for Payer: Humana Medicare	$180.18
Rate for Payer: Kaiser Permanente Commercial	$386.10
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$180.18
Rate for Payer: MDX Hawaii PPO	$416.13
Rate for Payer: Ohana Health Plan Medicaid	$180.18
Rate for Payer: Ohana Health Plan Medicare	$180.18
Rate for Payer: UnitedHealthcare Medicare	$180.18
Rate for Payer: University Health Alliance Commercial	$312.70

Know your out-of-pocket cost for care.

All Charges