Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

sacubitril-valsartan 24 mg-26 mg tab [HHSC]

Facility

$59.27

Service Code	HCPCS A9270
Hospital Charge Code	2501023
Hospital Revenue Code	637
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$57.49
Rate for Payer: AlohaCare Medicaid	$29.64
Rate for Payer: AlohaCare Medicaid	$4.75
Rate for Payer: AlohaCare Medicaid	$35.60
Rate for Payer: AlohaCare Medicare	$35.60
Rate for Payer: AlohaCare Medicare	$29.64
Rate for Payer: AlohaCare Medicare	$4.75
Rate for Payer: Cash Price	$6.18
Rate for Payer: Cash Price	$38.53
Rate for Payer: Cash Price	$46.28
Rate for Payer: Devoted Health Medicare	$39.16
Rate for Payer: Devoted Health Medicare	$32.60
Rate for Payer: Devoted Health Medicare	$5.22
Rate for Payer: Hawaii Medical Service Association Medicare	$4.75
Rate for Payer: Hawaii Medical Service Association Medicare	$29.64
Rate for Payer: Hawaii Medical Service Association Medicare	$35.60
Rate for Payer: Hawaii Western Management Group Commercial	$9.03
Rate for Payer: Hawaii Western Management Group Commercial	$56.31
Rate for Payer: Hawaii Western Management Group Commercial	$67.64
Rate for Payer: Health Management Network Commercial	$50.38
Rate for Payer: Health Management Network Commercial	$60.52
Rate for Payer: Health Management Network Commercial	$8.07
Rate for Payer: Humana Medicare	$35.60
Rate for Payer: Humana Medicare	$4.75
Rate for Payer: Humana Medicare	$29.64
Rate for Payer: Kaiser Permanente Commercial	$64.08
Rate for Payer: Kaiser Permanente Commercial	$53.34
Rate for Payer: Kaiser Permanente Commercial	$8.55
Rate for Payer: Kaiser Permanente Medicaid	$4.84
Rate for Payer: Kaiser Permanente Medicaid	$30.23
Rate for Payer: Kaiser Permanente Medicaid	$36.31
Rate for Payer: Kaiser Permanente Medicare	$29.64
Rate for Payer: Kaiser Permanente Medicare	$35.60
Rate for Payer: Kaiser Permanente Medicare	$4.75
Rate for Payer: MDX Hawaii PPO	$57.49
Rate for Payer: MDX Hawaii PPO	$69.06
Rate for Payer: MDX Hawaii PPO	$9.21
Rate for Payer: Ohana Health Plan Medicaid	$35.60
Rate for Payer: Ohana Health Plan Medicaid	$29.64
Rate for Payer: Ohana Health Plan Medicaid	$4.75
Rate for Payer: Ohana Health Plan Medicare	$29.64
Rate for Payer: Ohana Health Plan Medicare	$35.60
Rate for Payer: Ohana Health Plan Medicare	$4.75
Rate for Payer: UnitedHealthcare Medicare	$29.64
Rate for Payer: UnitedHealthcare Medicare	$4.75
Rate for Payer: UnitedHealthcare Medicare	$35.60
Rate for Payer: University Health Alliance Commercial	$51.90
Rate for Payer: University Health Alliance Commercial	$43.20
Rate for Payer: University Health Alliance Commercial	$6.92

sacubitril-valsartan 24 mg-26 mg tab [HHSC]

Facility

$71.20

Service Code	HCPCS A9270
Hospital Charge Code	2501023
Hospital Revenue Code	250
Min. Negotiated Rate	$60.52
Max. Negotiated Rate	$69.06
Rate for Payer: Cash Price	$46.28
Rate for Payer: Cash Price	$38.53
Rate for Payer: Cash Price	$6.18
Rate for Payer: Health Management Network Commercial	$8.07
Rate for Payer: Health Management Network Commercial	$50.38
Rate for Payer: Health Management Network Commercial	$60.52
Rate for Payer: Kaiser Permanente Commercial	$8.55
Rate for Payer: Kaiser Permanente Commercial	$53.34
Rate for Payer: Kaiser Permanente Commercial	$64.08
Rate for Payer: MDX Hawaii PPO	$69.06
Rate for Payer: MDX Hawaii PPO	$57.49
Rate for Payer: MDX Hawaii PPO	$9.21

Salicylate FSI

Facility

$198.00

Service Code	HCPCS G0480
Hospital Charge Code	8118042
Hospital Revenue Code	301
Min. Negotiated Rate	$47.96
Max. Negotiated Rate	$192.06
Rate for Payer: AlohaCare Medicaid	$99.00
Rate for Payer: AlohaCare Medicare	$99.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cash Price	$128.70
Rate for Payer: Devoted Health Medicare	$108.90
Rate for Payer: Hawaii Medical Service Association Commercial	$143.04
Rate for Payer: Hawaii Medical Service Association Medicare	$99.00
Rate for Payer: Hawaii Western Management Group Commercial	$188.10
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Humana Medicare	$99.00
Rate for Payer: Kaiser Permanente Commercial	$178.20
Rate for Payer: Kaiser Permanente Medicaid	$100.98
Rate for Payer: Kaiser Permanente Medicare	$99.00
Rate for Payer: MDX Hawaii PPO	$192.06
Rate for Payer: Ohana Health Plan Medicaid	$99.00
Rate for Payer: Ohana Health Plan Medicare	$99.00
Rate for Payer: UnitedHealthcare Medicaid	$47.96
Rate for Payer: UnitedHealthcare Medicare	$99.00
Rate for Payer: University Health Alliance Commercial	$144.32

Salicylate FSI

Facility

$198.00

Service Code	HCPCS G0480
Hospital Charge Code	8118042
Hospital Revenue Code	301
Min. Negotiated Rate	$168.30
Max. Negotiated Rate	$192.06
Rate for Payer: Cash Price	$128.70
Rate for Payer: Health Management Network Commercial	$168.30
Rate for Payer: Kaiser Permanente Commercial	$178.20
Rate for Payer: MDX Hawaii PPO	$192.06

SALIVARY GLAND PROCEDURES

Facility

$23,405.33

Service Code	MSDRG 139
Min. Negotiated Rate	$23,405.33
Max. Negotiated Rate	$23,405.33
Rate for Payer: Hawaii Medical Service Association Commercial	$23,405.33

SARS CoV-2 and Influenza PCR FSI

Facility

$561.00

Service Code	HCPCS 87636 QW
Hospital Charge Code	9343541
Hospital Revenue Code	306
Min. Negotiated Rate	$142.63
Max. Negotiated Rate	$544.17
Rate for Payer: AlohaCare Medicaid	$280.50
Rate for Payer: AlohaCare Medicare	$280.50
Rate for Payer: Cash Price	$364.65
Rate for Payer: Cash Price	$364.65
Rate for Payer: Devoted Health Medicare	$308.55
Rate for Payer: Hawaii Medical Service Association ABD	$142.63
Rate for Payer: Hawaii Medical Service Association Commercial	$178.29
Rate for Payer: Hawaii Medical Service Association Medicare	$280.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$142.63
Rate for Payer: Hawaii Western Management Group Commercial	$142.63
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Humana Medicare	$280.50
Rate for Payer: Kaiser Permanente Commercial	$504.90
Rate for Payer: Kaiser Permanente Medicaid	$286.11
Rate for Payer: Kaiser Permanente Medicare	$280.50
Rate for Payer: MDX Hawaii PPO	$544.17
Rate for Payer: Ohana Health Plan Medicaid	$280.50
Rate for Payer: Ohana Health Plan Medicare	$280.50
Rate for Payer: UnitedHealthcare Medicaid	$142.63
Rate for Payer: UnitedHealthcare Medicare	$280.50
Rate for Payer: University Health Alliance Commercial	$408.91

SARS CoV-2 and Influenza PCR FSI

Facility

$561.00

Service Code	HCPCS 87636 QW
Hospital Charge Code	9343541
Hospital Revenue Code	306
Min. Negotiated Rate	$476.85
Max. Negotiated Rate	$544.17
Rate for Payer: Cash Price	$364.65
Rate for Payer: Health Management Network Commercial	$476.85
Rate for Payer: Kaiser Permanente Commercial	$504.90
Rate for Payer: MDX Hawaii PPO	$544.17

SARS-CoV-2 (COVID-19) AG (Sofia) POC (RE)

Facility

$589.00

Service Code	HCPCS 87428 QW
Hospital Charge Code	9578803
Hospital Revenue Code	306
Min. Negotiated Rate	$500.65
Max. Negotiated Rate	$571.33
Rate for Payer: Cash Price	$382.85
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: Kaiser Permanente Commercial	$530.10
Rate for Payer: MDX Hawaii PPO	$571.33

SARS-CoV-2 (COVID-19) AG (Sofia) POC (RE)

Facility

$589.00

Service Code	HCPCS 87428 QW
Hospital Charge Code	9578803
Hospital Revenue Code	306
Min. Negotiated Rate	$63.59
Max. Negotiated Rate	$571.33
Rate for Payer: AlohaCare Medicaid	$294.50
Rate for Payer: AlohaCare Medicare	$294.50
Rate for Payer: Cash Price	$382.85
Rate for Payer: Cash Price	$382.85
Rate for Payer: Devoted Health Medicare	$323.95
Rate for Payer: Hawaii Medical Service Association ABD	$73.49
Rate for Payer: Hawaii Medical Service Association Commercial	$87.86
Rate for Payer: Hawaii Medical Service Association Medicare	$294.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$73.49
Rate for Payer: Hawaii Western Management Group Commercial	$70.29
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: Humana Medicare	$294.50
Rate for Payer: Kaiser Permanente Commercial	$530.10
Rate for Payer: Kaiser Permanente Medicaid	$300.39
Rate for Payer: Kaiser Permanente Medicare	$294.50
Rate for Payer: MDX Hawaii PPO	$571.33
Rate for Payer: Ohana Health Plan Medicaid	$294.50
Rate for Payer: Ohana Health Plan Medicare	$294.50
Rate for Payer: UnitedHealthcare Medicaid	$63.59
Rate for Payer: UnitedHealthcare Medicare	$294.50
Rate for Payer: University Health Alliance Commercial	$429.32

SARS-CoV-2 (Covid-19) AG (Sofia) POCT

Facility

$244.00

Service Code	HCPCS 87426 QW
Hospital Charge Code	9578812
Hospital Revenue Code	300
Min. Negotiated Rate	$35.33
Max. Negotiated Rate	$236.68
Rate for Payer: AlohaCare Medicaid	$122.00
Rate for Payer: AlohaCare Medicare	$122.00
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$134.20
Rate for Payer: Hawaii Medical Service Association ABD	$45.00
Rate for Payer: Hawaii Medical Service Association Commercial	$44.16
Rate for Payer: Hawaii Medical Service Association Medicare	$122.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$45.00
Rate for Payer: Hawaii Western Management Group Commercial	$35.33
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Humana Medicare	$122.00
Rate for Payer: Kaiser Permanente Commercial	$219.60
Rate for Payer: Kaiser Permanente Medicaid	$124.44
Rate for Payer: Kaiser Permanente Medicare	$122.00
Rate for Payer: MDX Hawaii PPO	$236.68
Rate for Payer: Ohana Health Plan Medicaid	$122.00
Rate for Payer: Ohana Health Plan Medicare	$122.00
Rate for Payer: UnitedHealthcare Medicaid	$35.33
Rate for Payer: UnitedHealthcare Medicare	$122.00
Rate for Payer: University Health Alliance Commercial	$177.85

SARS-CoV-2 (Covid-19) AG (Sofia) POCT

Facility

$244.00

Service Code	HCPCS 87426 QW
Hospital Charge Code	9578812
Hospital Revenue Code	300
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$158.60
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Kaiser Permanente Commercial	$219.60
Rate for Payer: MDX Hawaii PPO	$236.68

SARS CoV-2 (COVID-19) by RT-PCR FSI

Facility

$245.00

Service Code	HCPCS U0001
Hospital Charge Code	8855655
Hospital Revenue Code	300
Min. Negotiated Rate	$208.25
Max. Negotiated Rate	$237.65
Rate for Payer: Cash Price	$159.25
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: MDX Hawaii PPO	$237.65

SARS CoV-2 (COVID-19) by RT-PCR FSI

Facility

$245.00

Service Code	HCPCS U0001
Hospital Charge Code	8855655
Hospital Revenue Code	300
Min. Negotiated Rate	$35.91
Max. Negotiated Rate	$237.65
Rate for Payer: AlohaCare Medicaid	$122.50
Rate for Payer: AlohaCare Medicare	$122.50
Rate for Payer: Cash Price	$159.25
Rate for Payer: Cash Price	$159.25
Rate for Payer: Devoted Health Medicare	$134.75
Rate for Payer: Hawaii Medical Service Association Commercial	$44.90
Rate for Payer: Hawaii Medical Service Association Medicare	$122.50
Rate for Payer: Hawaii Western Management Group Commercial	$232.75
Rate for Payer: Health Management Network Commercial	$208.25
Rate for Payer: Humana Medicare	$122.50
Rate for Payer: Kaiser Permanente Commercial	$220.50
Rate for Payer: Kaiser Permanente Medicaid	$124.95
Rate for Payer: Kaiser Permanente Medicare	$122.50
Rate for Payer: MDX Hawaii PPO	$237.65
Rate for Payer: Ohana Health Plan Medicaid	$122.50
Rate for Payer: Ohana Health Plan Medicare	$122.50
Rate for Payer: UnitedHealthcare Medicaid	$35.91
Rate for Payer: UnitedHealthcare Medicare	$122.50
Rate for Payer: University Health Alliance Commercial	$178.58

SARS-CoV-2 (COVID-19) by RT-PCR FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8867164
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS-CoV-2 (COVID-19) by RT-PCR FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8867164
Hospital Revenue Code	306
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

SARS-CoV-2 (COVID-19)/FLU AB (Sofia) POC (RE)

Facility

$589.00

Service Code	HCPCS 87428 QW
Hospital Charge Code	9578804
Hospital Revenue Code	306
Min. Negotiated Rate	$63.59
Max. Negotiated Rate	$571.33
Rate for Payer: AlohaCare Medicaid	$294.50
Rate for Payer: AlohaCare Medicare	$294.50
Rate for Payer: Cash Price	$382.85
Rate for Payer: Cash Price	$382.85
Rate for Payer: Devoted Health Medicare	$323.95
Rate for Payer: Hawaii Medical Service Association ABD	$73.49
Rate for Payer: Hawaii Medical Service Association Commercial	$87.86
Rate for Payer: Hawaii Medical Service Association Medicare	$294.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$73.49
Rate for Payer: Hawaii Western Management Group Commercial	$70.29
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: Humana Medicare	$294.50
Rate for Payer: Kaiser Permanente Commercial	$530.10
Rate for Payer: Kaiser Permanente Medicaid	$300.39
Rate for Payer: Kaiser Permanente Medicare	$294.50
Rate for Payer: MDX Hawaii PPO	$571.33
Rate for Payer: Ohana Health Plan Medicaid	$294.50
Rate for Payer: Ohana Health Plan Medicare	$294.50
Rate for Payer: UnitedHealthcare Medicaid	$63.59
Rate for Payer: UnitedHealthcare Medicare	$294.50
Rate for Payer: University Health Alliance Commercial	$429.32

SARS-CoV-2 (COVID-19)/FLU AB (Sofia) POC (RE)

Facility

$589.00

Service Code	HCPCS 87428 QW
Hospital Charge Code	9578804
Hospital Revenue Code	306
Min. Negotiated Rate	$500.65
Max. Negotiated Rate	$571.33
Rate for Payer: Cash Price	$382.85
Rate for Payer: Health Management Network Commercial	$500.65
Rate for Payer: Kaiser Permanente Commercial	$530.10
Rate for Payer: MDX Hawaii PPO	$571.33

SARS-CoV-2 (COVID-19) IgG Antibody, Qual FSI

Facility

$109.00

Service Code	HCPCS 86769
Hospital Charge Code	8879007
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$54.50
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Devoted Health Medicare	$59.95
Rate for Payer: Hawaii Medical Service Association ABD	$42.13
Rate for Payer: Hawaii Medical Service Association Commercial	$52.66
Rate for Payer: Hawaii Medical Service Association Medicare	$54.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$42.13
Rate for Payer: Hawaii Western Management Group Commercial	$42.13
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$54.50
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$54.50
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$54.50
Rate for Payer: Ohana Health Plan Medicare	$54.50
Rate for Payer: UnitedHealthcare Medicaid	$42.13
Rate for Payer: UnitedHealthcare Medicare	$54.50
Rate for Payer: University Health Alliance Commercial	$79.45

SARS-CoV-2 (COVID-19) IgG Antibody, Qual FSI

Facility

$109.00

Service Code	HCPCS 86769
Hospital Charge Code	8879007
Hospital Revenue Code	302
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

SARS-Cov-2 (COVID -19) PCR, Cepheid FSI

Facility

$265.00

Service Code	HCPCS 87635
Hospital Charge Code	12930674
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$257.05
Rate for Payer: AlohaCare Medicaid	$132.50
Rate for Payer: AlohaCare Medicare	$132.50
Rate for Payer: Cash Price	$172.25
Rate for Payer: Cash Price	$172.25
Rate for Payer: Devoted Health Medicare	$145.75
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$132.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$225.25
Rate for Payer: Humana Medicare	$132.50
Rate for Payer: Kaiser Permanente Commercial	$238.50
Rate for Payer: Kaiser Permanente Medicaid	$135.15
Rate for Payer: Kaiser Permanente Medicare	$132.50
Rate for Payer: MDX Hawaii PPO	$257.05
Rate for Payer: Ohana Health Plan Medicaid	$132.50
Rate for Payer: Ohana Health Plan Medicare	$132.50
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$132.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS-Cov-2 (COVID -19) PCR, Cepheid FSI

Facility

$265.00

Service Code	HCPCS 87635
Hospital Charge Code	12930674
Hospital Revenue Code	306
Min. Negotiated Rate	$225.25
Max. Negotiated Rate	$257.05
Rate for Payer: Cash Price	$172.25
Rate for Payer: Health Management Network Commercial	$225.25
Rate for Payer: Kaiser Permanente Commercial	$238.50
Rate for Payer: MDX Hawaii PPO	$257.05

SARS-CoV-2 (COVID-19) Rapid (ID Now) FSI

Facility

$179.00

Service Code	HCPCS 87635 QW
Hospital Charge Code	9256869
Hospital Revenue Code	306
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

SARS-CoV-2 (COVID-19) Rapid (ID Now) FSI

Facility

$179.00

Service Code	HCPCS 87635 QW
Hospital Charge Code	9256869
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

SARS-CoV-2 (COVID-19) RNA by TMA FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8896718
Hospital Revenue Code	306
Min. Negotiated Rate	$152.15
Max. Negotiated Rate	$173.63
Rate for Payer: Cash Price	$116.35
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63

SARS-CoV-2 (COVID-19) RNA by TMA FSI

Facility

$179.00

Service Code	HCPCS 87635
Hospital Charge Code	8896718
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$173.63
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$89.50
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$98.45
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$89.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$89.50
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$89.50
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$89.50
Rate for Payer: Ohana Health Plan Medicare	$89.50
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$89.50
Rate for Payer: University Health Alliance Commercial	$94.96

Know your out-of-pocket cost for care.

All Charges