Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC ASSAY OF CK (CPK) - CK

Facility

$55.00

Service Code	HCPCS 82550
Hospital Charge Code	3018255001
Hospital Revenue Code	301
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$33.00
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: MDX Hawaii PPO	$53.35

HC ASSAY OF COPPER - COPPER 24HR URINE

Facility

$104.00

Service Code	HCPCS 82525
Hospital Charge Code	3018252502
Hospital Revenue Code	301
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$12.41
Rate for Payer: AlohaCare Medicare	$12.41
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$13.65
Rate for Payer: Hawaii Medical Service Association ABD	$17.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15.51
Rate for Payer: Hawaii Medical Service Association Medicare	$12.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.01
Rate for Payer: Hawaii Western Management Group Commercial	$12.41
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$12.41
Rate for Payer: Kaiser Permanente Commercial	$65.52
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$12.41
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$13.65
Rate for Payer: Ohana Health Plan Medicare	$12.41
Rate for Payer: UnitedHealthcare Medicaid	$17.15
Rate for Payer: UnitedHealthcare Medicare	$12.41
Rate for Payer: University Health Alliance Commercial	$32.08

HC ASSAY OF COPPER - COPPER 24HR URINE

Facility

$104.00

Service Code	HCPCS 82525
Hospital Charge Code	3018252502
Hospital Revenue Code	301
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: MDX Hawaii PPO	$100.88

HC ASSAY OF COPPER - COPPER, SERUM

Facility

$104.00

Service Code	HCPCS 82525
Hospital Charge Code	3018252504
Hospital Revenue Code	301
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$100.88
Rate for Payer: AlohaCare Medicaid	$12.41
Rate for Payer: AlohaCare Medicare	$12.41
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$13.65
Rate for Payer: Hawaii Medical Service Association ABD	$17.15
Rate for Payer: Hawaii Medical Service Association Commercial	$15.51
Rate for Payer: Hawaii Medical Service Association Medicare	$12.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.01
Rate for Payer: Hawaii Western Management Group Commercial	$12.41
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: Humana Medicare	$12.41
Rate for Payer: Kaiser Permanente Commercial	$65.52
Rate for Payer: Kaiser Permanente Medicaid	$53.04
Rate for Payer: Kaiser Permanente Medicare	$12.41
Rate for Payer: MDX Hawaii PPO	$100.88
Rate for Payer: Ohana Health Plan Medicaid	$13.65
Rate for Payer: Ohana Health Plan Medicare	$12.41
Rate for Payer: UnitedHealthcare Medicaid	$17.15
Rate for Payer: UnitedHealthcare Medicare	$12.41
Rate for Payer: University Health Alliance Commercial	$32.08

HC ASSAY OF COPPER - COPPER, SERUM

Facility

$104.00

Service Code	HCPCS 82525
Hospital Charge Code	3018252504
Hospital Revenue Code	301
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$100.88
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Management Network Commercial	$88.40
Rate for Payer: MDX Hawaii PPO	$100.88

HC ASSAY OF C-PEPTIDE - C-PEPTIDE

Facility

$175.00

Service Code	HCPCS 84681
Hospital Charge Code	3018468101
Hospital Revenue Code	301
Min. Negotiated Rate	$148.75
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75

HC ASSAY OF C-PEPTIDE - C-PEPTIDE

Facility

$175.00

Service Code	HCPCS 84681
Hospital Charge Code	3018468101
Hospital Revenue Code	301
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$20.81
Rate for Payer: AlohaCare Medicare	$20.81
Rate for Payer: Cash Price	$105.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$22.89
Rate for Payer: Hawaii Medical Service Association ABD	$28.75
Rate for Payer: Hawaii Medical Service Association Commercial	$26.01
Rate for Payer: Hawaii Medical Service Association Medicare	$20.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.19
Rate for Payer: Hawaii Western Management Group Commercial	$20.81
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$20.81
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$20.81
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$22.89
Rate for Payer: Ohana Health Plan Medicare	$20.81
Rate for Payer: UnitedHealthcare Medicaid	$28.75
Rate for Payer: UnitedHealthcare Medicare	$20.81
Rate for Payer: University Health Alliance Commercial	$53.78

HC ASSAY OF CREATININE - CREATININE BLOOD

Facility

$43.00

Service Code	HCPCS 82565
Hospital Charge Code	3018256501
Hospital Revenue Code	301
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: MDX Hawaii PPO	$41.71

HC ASSAY OF CREATININE - CREATININE BLOOD

Facility

$43.00

Service Code	HCPCS 82565
Hospital Charge Code	3018256501
Hospital Revenue Code	301
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$41.71
Rate for Payer: AlohaCare Medicaid	$5.12
Rate for Payer: AlohaCare Medicare	$5.12
Rate for Payer: Cash Price	$25.80
Rate for Payer: Cash Price	$25.80
Rate for Payer: Devoted Health Medicare	$5.63
Rate for Payer: Hawaii Medical Service Association ABD	$7.07
Rate for Payer: Hawaii Medical Service Association Commercial	$6.40
Rate for Payer: Hawaii Medical Service Association Medicare	$5.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.42
Rate for Payer: Hawaii Western Management Group Commercial	$5.12
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Humana Medicare	$5.12
Rate for Payer: Kaiser Permanente Commercial	$27.09
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicare	$5.12
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: Ohana Health Plan Medicaid	$5.63
Rate for Payer: Ohana Health Plan Medicare	$5.12
Rate for Payer: UnitedHealthcare Medicaid	$7.07
Rate for Payer: UnitedHealthcare Medicare	$5.12
Rate for Payer: University Health Alliance Commercial	$13.25

HC ASSAY OF CREATININE - CREATININE BLOOD POCT

Facility

$43.00

Service Code	HCPCS 82565
Hospital Charge Code	3018256502
Hospital Revenue Code	301
Min. Negotiated Rate	$36.55
Max. Negotiated Rate	$41.71
Rate for Payer: Cash Price	$25.80
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: MDX Hawaii PPO	$41.71

HC ASSAY OF CREATININE - CREATININE BLOOD POCT

Facility

$43.00

Service Code	HCPCS 82565
Hospital Charge Code	3018256502
Hospital Revenue Code	301
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$41.71
Rate for Payer: AlohaCare Medicaid	$5.12
Rate for Payer: AlohaCare Medicare	$5.12
Rate for Payer: Cash Price	$25.80
Rate for Payer: Cash Price	$25.80
Rate for Payer: Devoted Health Medicare	$5.63
Rate for Payer: Hawaii Medical Service Association ABD	$7.07
Rate for Payer: Hawaii Medical Service Association Commercial	$6.40
Rate for Payer: Hawaii Medical Service Association Medicare	$5.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.42
Rate for Payer: Hawaii Western Management Group Commercial	$5.12
Rate for Payer: Health Management Network Commercial	$36.55
Rate for Payer: Humana Medicare	$5.12
Rate for Payer: Kaiser Permanente Commercial	$27.09
Rate for Payer: Kaiser Permanente Medicaid	$21.93
Rate for Payer: Kaiser Permanente Medicare	$5.12
Rate for Payer: MDX Hawaii PPO	$41.71
Rate for Payer: Ohana Health Plan Medicaid	$5.63
Rate for Payer: Ohana Health Plan Medicare	$5.12
Rate for Payer: UnitedHealthcare Medicaid	$7.07
Rate for Payer: UnitedHealthcare Medicare	$5.12
Rate for Payer: University Health Alliance Commercial	$13.25

HC ASSAY OF CYCLOSPORINE - CYCLOSPORINE

Facility

$151.00

Service Code	HCPCS 80158
Hospital Charge Code	3018015801
Hospital Revenue Code	301
Min. Negotiated Rate	$18.05
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$18.05
Rate for Payer: AlohaCare Medicare	$18.05
Rate for Payer: Cash Price	$90.60
Rate for Payer: Cash Price	$90.60
Rate for Payer: Devoted Health Medicare	$19.86
Rate for Payer: Hawaii Medical Service Association ABD	$24.95
Rate for Payer: Hawaii Medical Service Association Commercial	$22.56
Rate for Payer: Hawaii Medical Service Association Medicare	$18.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.20
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$18.05
Rate for Payer: Kaiser Permanente Commercial	$95.13
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$18.05
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$19.86
Rate for Payer: Ohana Health Plan Medicare	$18.05
Rate for Payer: UnitedHealthcare Medicaid	$24.95
Rate for Payer: UnitedHealthcare Medicare	$18.05
Rate for Payer: University Health Alliance Commercial	$46.68

HC ASSAY OF CYCLOSPORINE - CYCLOSPORINE

Facility

$151.00

Service Code	HCPCS 80158
Hospital Charge Code	3018015801
Hospital Revenue Code	301
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$90.60
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: MDX Hawaii PPO	$146.47

HC ASSAY OF DIBUCAINE NUMBER SO

Facility

$103.00

Service Code	HCPCS 82638
Hospital Charge Code	3018263801
Hospital Revenue Code	301
Min. Negotiated Rate	$10.27
Max. Negotiated Rate	$99.91
Rate for Payer: AlohaCare Medicaid	$12.25
Rate for Payer: AlohaCare Medicare	$12.25
Rate for Payer: Cash Price	$61.80
Rate for Payer: Cash Price	$61.80
Rate for Payer: Devoted Health Medicare	$13.47
Rate for Payer: Hawaii Medical Service Association ABD	$10.27
Rate for Payer: Hawaii Medical Service Association Commercial	$15.31
Rate for Payer: Hawaii Medical Service Association Medicare	$12.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.92
Rate for Payer: Hawaii Western Management Group Commercial	$12.25
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$12.25
Rate for Payer: Kaiser Permanente Commercial	$64.89
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$12.25
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$13.47
Rate for Payer: Ohana Health Plan Medicare	$12.25
Rate for Payer: UnitedHealthcare Medicaid	$10.27
Rate for Payer: UnitedHealthcare Medicare	$12.25
Rate for Payer: University Health Alliance Commercial	$31.65

HC ASSAY OF DIBUCAINE NUMBER SO

Facility

$103.00

Service Code	HCPCS 82638
Hospital Charge Code	3018263801
Hospital Revenue Code	301
Min. Negotiated Rate	$87.55
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: MDX Hawaii PPO	$99.91

HC ASSAY OF ERYTHROPOIETIN - ERYTHROPOIETIN

Facility

$158.00

Service Code	HCPCS 82668
Hospital Charge Code	3018266801
Hospital Revenue Code	301
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: MDX Hawaii PPO	$153.26

HC ASSAY OF ERYTHROPOIETIN - ERYTHROPOIETIN

Facility

$158.00

Service Code	HCPCS 82668
Hospital Charge Code	3018266801
Hospital Revenue Code	301
Min. Negotiated Rate	$18.79
Max. Negotiated Rate	$153.26
Rate for Payer: AlohaCare Medicaid	$18.79
Rate for Payer: AlohaCare Medicare	$18.79
Rate for Payer: Cash Price	$94.80
Rate for Payer: Cash Price	$94.80
Rate for Payer: Devoted Health Medicare	$20.67
Rate for Payer: Hawaii Medical Service Association ABD	$25.97
Rate for Payer: Hawaii Medical Service Association Commercial	$23.49
Rate for Payer: Hawaii Medical Service Association Medicare	$18.79
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.27
Rate for Payer: Hawaii Western Management Group Commercial	$18.79
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Humana Medicare	$18.79
Rate for Payer: Kaiser Permanente Commercial	$99.54
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: Kaiser Permanente Medicare	$18.79
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: Ohana Health Plan Medicaid	$20.67
Rate for Payer: Ohana Health Plan Medicare	$18.79
Rate for Payer: UnitedHealthcare Medicaid	$25.97
Rate for Payer: UnitedHealthcare Medicare	$18.79
Rate for Payer: University Health Alliance Commercial	$48.58

HC ASSAY OF ESTROGEN - ESTROGENS, TOTAL

Facility

$182.00

Service Code	HCPCS 82672
Hospital Charge Code	3018267201
Hospital Revenue Code	301
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$176.54
Rate for Payer: AlohaCare Medicaid	$21.70
Rate for Payer: AlohaCare Medicare	$21.70
Rate for Payer: Cash Price	$109.20
Rate for Payer: Cash Price	$109.20
Rate for Payer: Devoted Health Medicare	$23.87
Rate for Payer: Hawaii Medical Service Association ABD	$29.97
Rate for Payer: Hawaii Medical Service Association Commercial	$27.12
Rate for Payer: Hawaii Medical Service Association Medicare	$21.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$31.47
Rate for Payer: Hawaii Western Management Group Commercial	$21.70
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: Humana Medicare	$21.70
Rate for Payer: Kaiser Permanente Commercial	$114.66
Rate for Payer: Kaiser Permanente Medicaid	$92.82
Rate for Payer: Kaiser Permanente Medicare	$21.70
Rate for Payer: MDX Hawaii PPO	$176.54
Rate for Payer: Ohana Health Plan Medicaid	$23.87
Rate for Payer: Ohana Health Plan Medicare	$21.70
Rate for Payer: UnitedHealthcare Medicaid	$29.97
Rate for Payer: UnitedHealthcare Medicare	$21.70
Rate for Payer: University Health Alliance Commercial	$56.05

HC ASSAY OF ESTROGEN - ESTROGENS, TOTAL

Facility

$182.00

Service Code	HCPCS 82672
Hospital Charge Code	3018267201
Hospital Revenue Code	301
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$109.20
Rate for Payer: Health Management Network Commercial	$154.70
Rate for Payer: MDX Hawaii PPO	$176.54

HC ASSAY OF ETHYLENE GLYCOL - ETHYLENE GLYCOL

Facility

$125.00

Service Code	HCPCS 82693
Hospital Charge Code	3018269301
Hospital Revenue Code	301
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: MDX Hawaii PPO	$121.25

HC ASSAY OF ETHYLENE GLYCOL - ETHYLENE GLYCOL

Facility

$125.00

Service Code	HCPCS 82693
Hospital Charge Code	3018269301
Hospital Revenue Code	301
Min. Negotiated Rate	$14.90
Max. Negotiated Rate	$121.25
Rate for Payer: AlohaCare Medicaid	$14.90
Rate for Payer: AlohaCare Medicare	$14.90
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Devoted Health Medicare	$16.39
Rate for Payer: Hawaii Medical Service Association ABD	$20.59
Rate for Payer: Hawaii Medical Service Association Commercial	$18.62
Rate for Payer: Hawaii Medical Service Association Medicare	$14.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.62
Rate for Payer: Hawaii Western Management Group Commercial	$14.90
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: Humana Medicare	$14.90
Rate for Payer: Kaiser Permanente Commercial	$78.75
Rate for Payer: Kaiser Permanente Medicaid	$63.75
Rate for Payer: Kaiser Permanente Medicare	$14.90
Rate for Payer: MDX Hawaii PPO	$121.25
Rate for Payer: Ohana Health Plan Medicaid	$16.39
Rate for Payer: Ohana Health Plan Medicare	$14.90
Rate for Payer: UnitedHealthcare Medicaid	$20.59
Rate for Payer: UnitedHealthcare Medicare	$14.90
Rate for Payer: University Health Alliance Commercial	$38.52

HC ASSAY OF FERRITIN - FERRITIN

Facility

$114.00

Service Code	HCPCS 82728
Hospital Charge Code	3018272801
Hospital Revenue Code	301
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$13.63
Rate for Payer: AlohaCare Medicare	$13.63
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cash Price	$68.40
Rate for Payer: Devoted Health Medicare	$14.99
Rate for Payer: Hawaii Medical Service Association ABD	$15.81
Rate for Payer: Hawaii Medical Service Association Commercial	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$13.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.60
Rate for Payer: Hawaii Western Management Group Commercial	$13.63
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$13.63
Rate for Payer: Kaiser Permanente Commercial	$71.82
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$13.63
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$14.99
Rate for Payer: Ohana Health Plan Medicare	$13.63
Rate for Payer: UnitedHealthcare Medicaid	$15.81
Rate for Payer: UnitedHealthcare Medicare	$13.63
Rate for Payer: University Health Alliance Commercial	$29.56

HC ASSAY OF FERRITIN - FERRITIN

Facility

$114.00

Service Code	HCPCS 82728
Hospital Charge Code	3018272801
Hospital Revenue Code	301
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$68.40
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: MDX Hawaii PPO	$110.58

HC ASSAY OF FETAL FIBRONECTIN - FETAL FIBRONECTIN

Facility

$540.00

Service Code	HCPCS 82731
Hospital Charge Code	3018273101
Hospital Revenue Code	301
Min. Negotiated Rate	$64.41
Max. Negotiated Rate	$523.80
Rate for Payer: AlohaCare Medicaid	$64.41
Rate for Payer: AlohaCare Medicare	$64.41
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Devoted Health Medicare	$70.85
Rate for Payer: Hawaii Medical Service Association ABD	$89.01
Rate for Payer: Hawaii Medical Service Association Commercial	$80.51
Rate for Payer: Hawaii Medical Service Association Medicare	$64.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$239.94
Rate for Payer: Hawaii Western Management Group Commercial	$64.41
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Humana Medicare	$64.41
Rate for Payer: Kaiser Permanente Commercial	$340.20
Rate for Payer: Kaiser Permanente Medicaid	$275.40
Rate for Payer: Kaiser Permanente Medicare	$64.41
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: Ohana Health Plan Medicaid	$70.85
Rate for Payer: Ohana Health Plan Medicare	$64.41
Rate for Payer: UnitedHealthcare Medicaid	$89.01
Rate for Payer: UnitedHealthcare Medicare	$64.41
Rate for Payer: University Health Alliance Commercial	$166.48

HC ASSAY OF FETAL FIBRONECTIN - FETAL FIBRONECTIN

Facility

$540.00

Service Code	HCPCS 82731
Hospital Charge Code	3018273101
Hospital Revenue Code	301
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$324.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: MDX Hawaii PPO	$523.80

Know your out-of-pocket cost for care.

All Charges