Kau Hospital

All Charges

Charge

Type

Setting

Price

HC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY

Facility

$1,545.00

Service Code	HCPCS 31577
Hospital Charge Code	4503157701
Hospital Revenue Code	450
Min. Negotiated Rate	$1,313.25
Max. Negotiated Rate	$1,498.65
Rate for Payer: Cash Price	$927.00
Rate for Payer: Health Management Network Commercial	$1,313.25
Rate for Payer: Kaiser Permanente Commercial	$1,390.50
Rate for Payer: MDX Hawaii PPO	$1,498.65

HC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN BODY

Facility

$1,545.00

Service Code	HCPCS 31577
Hospital Charge Code	4503157701
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$772.50
Rate for Payer: AlohaCare Medicare	$478.95
Rate for Payer: Cash Price	$927.00
Rate for Payer: Cash Price	$927.00
Rate for Payer: Devoted Health Medicare	$525.30
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	$478.95
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,467.75
Rate for Payer: Health Management Network Commercial	$1,313.25
Rate for Payer: Humana Medicare	$478.95
Rate for Payer: Kaiser Permanente Commercial	$1,390.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$478.95
Rate for Payer: MDX Hawaii PPO	$1,498.65
Rate for Payer: Ohana Health Plan Medicaid	$478.95
Rate for Payer: Ohana Health Plan Medicare	$478.95
Rate for Payer: UnitedHealthcare Medicare	$478.95
Rate for Payer: University Health Alliance Commercial	$1,126.15

HC LAYR CLOS WND FACE,FACIAL 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12055
Hospital Charge Code	7611205501
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 FACE,FACIAL 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12055
Hospital Charge Code	7611205501
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$795.00
Rate for Payer: AlohaCare Medicare	$492.90
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$540.60
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	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC LAYR CLOS WND FACE,FACIAL 20.1-30 CM

Facility

$1,557.00

Service Code	HCPCS 12056
Hospital Charge Code	3611205601
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$778.50
Rate for Payer: AlohaCare Medicare	$482.67
Rate for Payer: Cash Price	$934.20
Rate for Payer: Cash Price	$934.20
Rate for Payer: Devoted Health Medicare	$529.38
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	$482.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,479.15
Rate for Payer: Health Management Network Commercial	$1,323.45
Rate for Payer: Humana Medicare	$482.67
Rate for Payer: Kaiser Permanente Commercial	$1,401.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$482.67
Rate for Payer: MDX Hawaii PPO	$1,510.29
Rate for Payer: Ohana Health Plan Medicaid	$482.67
Rate for Payer: Ohana Health Plan Medicare	$482.67
Rate for Payer: UnitedHealthcare Medicare	$482.67
Rate for Payer: University Health Alliance Commercial	$1,134.90

HC LAYR CLOS WND FACE,FACIAL 20.1-30 CM

Facility

$1,557.00

Service Code	HCPCS 12056
Hospital Charge Code	3611205601
Hospital Revenue Code	450
Min. Negotiated Rate	$1,323.45
Max. Negotiated Rate	$1,510.29
Rate for Payer: Cash Price	$934.20
Rate for Payer: Health Management Network Commercial	$1,323.45
Rate for Payer: Kaiser Permanente Commercial	$1,401.30
Rate for Payer: MDX Hawaii PPO	$1,510.29

HC LAYR CLOS WND FACE,FACIAL <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12051
Hospital Charge Code	4501205101
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 FACE,FACIAL <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12051
Hospital Charge Code	4501205101
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$795.00
Rate for Payer: AlohaCare Medicare	$492.90
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$540.60
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	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$4,035.20

HC LAYR CLOS WND FACE,FACIAL >30 CM

Facility

$1,590.00

Service Code	HCPCS 12057
Hospital Charge Code	3611205701
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 FACE,FACIAL >30 CM

Facility

$1,590.00

Service Code	HCPCS 12057
Hospital Charge Code	3611205701
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$795.00
Rate for Payer: AlohaCare Medicare	$492.90
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$540.60
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	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC LAYR CLOS WND REST BODY <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12041
Hospital Charge Code	4501204101
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 REST BODY <2.5 CM

Facility

$1,590.00

Service Code	HCPCS 12041
Hospital Charge Code	4501204101
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$795.00
Rate for Payer: AlohaCare Medicare	$492.90
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$540.60
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	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC LAYR CLOS WND REST BODY 2.6-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12042
Hospital Charge Code	4501204201
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$795.00
Rate for Payer: AlohaCare Medicare	$492.90
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$540.60
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	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$1,158.95

HC LAYR CLOS WND REST BODY 2.6-7.5 CM

Facility

$1,590.00

Service Code	HCPCS 12042
Hospital Charge Code	4501204201
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 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12035
Hospital Charge Code	4501203501
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	$492.90
Rate for Payer: Cash Price	$954.00
Rate for Payer: Cash Price	$954.00
Rate for Payer: Devoted Health Medicare	$540.60
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	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$5,160.40

HC LAYR CLOS WND TRUNK,ARM,LEG 12.6-20 CM

Facility

$1,590.00

Service Code	HCPCS 12035
Hospital Charge Code	4501203501
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 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 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	$755.16
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Devoted Health Medicare	$828.24
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	$755.16
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	$755.16
Rate for Payer: Kaiser Permanente Commercial	$2,192.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$755.16
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: Ohana Health Plan Medicaid	$755.16
Rate for Payer: Ohana Health Plan Medicare	$755.16
Rate for Payer: UnitedHealthcare Medicare	$755.16
Rate for Payer: University Health Alliance Commercial	$1,775.60

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 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	$492.90
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	$540.60
Rate for Payer: Hawaii Medical Service Association Commercial	$519.15
Rate for Payer: Hawaii Medical Service Association Medicare	$492.90
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	$492.90
Rate for Payer: Kaiser Permanente Commercial	$1,431.00
Rate for Payer: Kaiser Permanente Medicaid	$810.90
Rate for Payer: Kaiser Permanente Medicare	$492.90
Rate for Payer: MDX Hawaii PPO	$1,542.30
Rate for Payer: Ohana Health Plan Medicaid	$492.90
Rate for Payer: Ohana Health Plan Medicare	$492.90
Rate for Payer: UnitedHealthcare Medicaid	$104.83
Rate for Payer: UnitedHealthcare Medicare	$492.90
Rate for Payer: University Health Alliance Commercial	$4,035.20

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	$34.72
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Devoted Health Medicare	$38.08
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	$34.72
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	$34.72
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$57.12
Rate for Payer: Kaiser Permanente Medicare	$34.72
Rate for Payer: MDX Hawaii PPO	$108.64
Rate for Payer: Ohana Health Plan Medicaid	$34.72
Rate for Payer: Ohana Health Plan Medicare	$34.72
Rate for Payer: UnitedHealthcare Medicaid	$18.51
Rate for Payer: UnitedHealthcare Medicare	$34.72
Rate for Payer: University Health Alliance Commercial	$34.63

HC LIPOPROTEIN A SO

Facility

$120.00

Service Code	HCPCS 83695
Hospital Charge Code	3018369501
Hospital Revenue Code	301
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$116.40
Rate for Payer: AlohaCare Medicaid	$60.00
Rate for Payer: AlohaCare Medicare	$37.20
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Devoted Health Medicare	$40.80
Rate for Payer: Hawaii Medical Service Association ABD	$12.66
Rate for Payer: Hawaii Medical Service Association Commercial	$17.90
Rate for Payer: Hawaii Medical Service Association Medicare	$37.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.32
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Humana Medicare	$37.20
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: Kaiser Permanente Medicare	$37.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: Ohana Health Plan Medicaid	$37.20
Rate for Payer: Ohana Health Plan Medicare	$37.20
Rate for Payer: UnitedHealthcare Medicaid	$12.66
Rate for Payer: UnitedHealthcare Medicare	$37.20
Rate for Payer: University Health Alliance Commercial	$33.47

HC LIPOPROTEIN A SO

Facility

$120.00

Service Code	HCPCS 83695
Hospital Charge Code	3018369501
Hospital Revenue Code	301
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$108.00
Rate for Payer: MDX Hawaii PPO	$116.40

HC LIPOPROTEIN, BLOOD, BY NMR SPECT - LIPOPROTEIN NMR

Facility

$287.00

Service Code	HCPCS 83704
Hospital Charge Code	3018370401
Hospital Revenue Code	301
Min. Negotiated Rate	$243.95
Max. Negotiated Rate	$278.39
Rate for Payer: Cash Price	$172.20
Rate for Payer: Health Management Network Commercial	$243.95
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: MDX Hawaii PPO	$278.39

Know your out-of-pocket cost for care.

All Charges