Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Alkaline Phosphatase FSI

Facility

$92.00

Service Code	HCPCS 84075
Hospital Charge Code	8117771
Hospital Revenue Code	301
Min. Negotiated Rate	$78.20
Max. Negotiated Rate	$89.24
Rate for Payer: Cash Price	$59.80
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$82.80
Rate for Payer: MDX Hawaii PPO	$89.24

Allergen Adult Foods SO

Facility

$146.00

Service Code	HCPCS 86003
Hospital Charge Code	8301848
Hospital Revenue Code	301
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$141.62
Rate for Payer: AlohaCare Medicaid	$73.00
Rate for Payer: AlohaCare Medicare	$73.00
Rate for Payer: Cash Price	$94.90
Rate for Payer: Cash Price	$94.90
Rate for Payer: Devoted Health Medicare	$80.30
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$73.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Humana Medicare	$73.00
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: Kaiser Permanente Medicare	$73.00
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: Ohana Health Plan Medicaid	$73.00
Rate for Payer: Ohana Health Plan Medicare	$73.00
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$73.00
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Adult Foods SO

Facility

$146.00

Service Code	HCPCS 86003
Hospital Charge Code	8301848
Hospital Revenue Code	301
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$94.90
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: MDX Hawaii PPO	$141.62

Allergen Almond, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117772
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Almond, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117772
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Alpha-Lactalbumin, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117773
Hospital Revenue Code	302
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$13.45
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$56.85

Allergen Alpha-Lactalbumin, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117773
Hospital Revenue Code	302
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

Allergen Alternaria tenuis, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117774
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Alternaria tenuis, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117774
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Aspergillus fumigatus, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117776
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Aspergillus fumigatus, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117776
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Aureobasidium pullulans, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117777
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Aureobasidium pullulans, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117777
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Bahia Grass, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117778
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Bahia Grass, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117778
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Banana, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117779
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Banana, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117779
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Beef, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117780
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Beef, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117780
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Bermuda Grass, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117781
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Bermuda Grass, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117781
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Beta-Lactoglobulin, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117782
Hospital Revenue Code	302
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$13.45
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$56.85

Allergen Beta-Lactoglobulin, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117782
Hospital Revenue Code	302
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

Allergen Candida albicans, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117784
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Candida albicans, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117784
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Know your out-of-pocket cost for care.

All Charges