Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG PART THRMPLSTN PTT

Facility

$89.00

Service Code	HCPCS 85730
Hospital Charge Code	H3050196
Hospital Revenue Code	305
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$88.11
Rate for Payer: AlohaCare Medicaid	$44.50
Rate for Payer: AlohaCare Medicare	$80.10
Rate for Payer: Cash Price	$57.85
Rate for Payer: Cash Price	$57.85
Rate for Payer: Devoted Health Medicare	$88.11
Rate for Payer: Hawaii Medical Service Association ABD	$8.30
Rate for Payer: Hawaii Medical Service Association Commercial	$7.51
Rate for Payer: Hawaii Medical Service Association Medicare	$80.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.72
Rate for Payer: Hawaii Western Management Group Commercial	$6.01
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Humana Medicare	$80.10
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: Kaiser Permanente Medicaid	$45.39
Rate for Payer: Kaiser Permanente Medicare	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33
Rate for Payer: Ohana Health Plan Medicaid	$80.10
Rate for Payer: Ohana Health Plan Medicare	$80.10
Rate for Payer: UnitedHealthcare Medicaid	$8.30
Rate for Payer: UnitedHealthcare Medicare	$80.10
Rate for Payer: University Health Alliance Commercial	$15.50

HCHG PART THRMPLSTN PTT

Facility

$89.00

Service Code	HCPCS 85730
Hospital Charge Code	H3050196
Hospital Revenue Code	305
Min. Negotiated Rate	$75.65
Max. Negotiated Rate	$86.33
Rate for Payer: Cash Price	$57.85
Rate for Payer: Health Management Network Commercial	$75.65
Rate for Payer: Kaiser Permanente Commercial	$80.10
Rate for Payer: MDX Hawaii PPO	$86.33

HCHG PARVOVIRUS B-19 IGG AB

Facility

$114.00

Service Code	HCPCS 86747
Hospital Charge Code	H3020664
Hospital Revenue Code	302
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

HCHG PARVOVIRUS B-19 IGG AB

Facility

$114.00

Service Code	HCPCS 86747
Hospital Charge Code	H3020664
Hospital Revenue Code	302
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$112.86
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$102.60
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$112.86
Rate for Payer: Hawaii Medical Service Association ABD	$20.77
Rate for Payer: Hawaii Medical Service Association Commercial	$18.79
Rate for Payer: Hawaii Medical Service Association Medicare	$102.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.81
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$102.60
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$102.60
Rate for Payer: Ohana Health Plan Medicare	$102.60
Rate for Payer: UnitedHealthcare Medicaid	$20.77
Rate for Payer: UnitedHealthcare Medicare	$102.60
Rate for Payer: University Health Alliance Commercial	$38.85

HCHG PARVOVIRUS B-19 IGM AB

Facility

$114.00

Service Code	HCPCS 86747
Hospital Charge Code	H3020666
Hospital Revenue Code	302
Min. Negotiated Rate	$96.90
Max. Negotiated Rate	$110.58
Rate for Payer: Cash Price	$74.10
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58

HCHG PARVOVIRUS B-19 IGM AB

Facility

$114.00

Service Code	HCPCS 86747
Hospital Charge Code	H3020666
Hospital Revenue Code	302
Min. Negotiated Rate	$15.03
Max. Negotiated Rate	$112.86
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$102.60
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$112.86
Rate for Payer: Hawaii Medical Service Association ABD	$20.77
Rate for Payer: Hawaii Medical Service Association Commercial	$18.79
Rate for Payer: Hawaii Medical Service Association Medicare	$102.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.81
Rate for Payer: Hawaii Western Management Group Commercial	$15.03
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$102.60
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$102.60
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$102.60
Rate for Payer: Ohana Health Plan Medicare	$102.60
Rate for Payer: UnitedHealthcare Medicaid	$20.77
Rate for Payer: UnitedHealthcare Medicare	$102.60
Rate for Payer: University Health Alliance Commercial	$38.85

HCHG PATELLA KNEE 1-2 VIEWS

Facility

$564.00

Service Code	HCPCS 73560
Hospital Charge Code	H3200614
Hospital Revenue Code	320
Min. Negotiated Rate	$479.40
Max. Negotiated Rate	$547.08
Rate for Payer: Cash Price	$366.60
Rate for Payer: Health Management Network Commercial	$479.40
Rate for Payer: Kaiser Permanente Commercial	$507.60
Rate for Payer: MDX Hawaii PPO	$547.08

HCHG PATELLA KNEE 1-2 VIEWS

Facility

$564.00

Service Code	HCPCS 73560
Hospital Charge Code	H3200614
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$558.36
Rate for Payer: AlohaCare Medicaid	$282.00
Rate for Payer: AlohaCare Medicare	$507.60
Rate for Payer: Cash Price	$366.60
Rate for Payer: Cash Price	$366.60
Rate for Payer: Devoted Health Medicare	$558.36
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$507.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$479.40
Rate for Payer: Humana Medicare	$507.60
Rate for Payer: Kaiser Permanente Commercial	$507.60
Rate for Payer: Kaiser Permanente Medicaid	$287.64
Rate for Payer: Kaiser Permanente Medicare	$507.60
Rate for Payer: MDX Hawaii PPO	$547.08
Rate for Payer: Ohana Health Plan Medicaid	$507.60
Rate for Payer: Ohana Health Plan Medicare	$507.60
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$507.60
Rate for Payer: University Health Alliance Commercial	$58.59

HCHG PELVIS INLET OUTLET, MIN 3 VIEWS

Facility

$644.00

Service Code	HCPCS 72190
Hospital Charge Code	H3200622
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$637.56
Rate for Payer: AlohaCare Medicaid	$322.00
Rate for Payer: AlohaCare Medicare	$579.60
Rate for Payer: Cash Price	$418.60
Rate for Payer: Cash Price	$418.60
Rate for Payer: Devoted Health Medicare	$637.56
Rate for Payer: Hawaii Medical Service Association ABD	$21.96
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$579.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$547.40
Rate for Payer: Humana Medicare	$579.60
Rate for Payer: Kaiser Permanente Commercial	$579.60
Rate for Payer: Kaiser Permanente Medicaid	$328.44
Rate for Payer: Kaiser Permanente Medicare	$579.60
Rate for Payer: MDX Hawaii PPO	$624.68
Rate for Payer: Ohana Health Plan Medicaid	$579.60
Rate for Payer: Ohana Health Plan Medicare	$579.60
Rate for Payer: UnitedHealthcare Medicaid	$21.96
Rate for Payer: UnitedHealthcare Medicare	$579.60
Rate for Payer: University Health Alliance Commercial	$78.55

HCHG PELVIS INLET OUTLET, MIN 3 VIEWS

Facility

$644.00

Service Code	HCPCS 72190
Hospital Charge Code	H3200622
Hospital Revenue Code	320
Min. Negotiated Rate	$547.40
Max. Negotiated Rate	$624.68
Rate for Payer: Cash Price	$418.60
Rate for Payer: Health Management Network Commercial	$547.40
Rate for Payer: Kaiser Permanente Commercial	$579.60
Rate for Payer: MDX Hawaii PPO	$624.68

HCHG PELVIS JUDET, MIN 3 VIEWS

Facility

$644.00

Service Code	HCPCS 72190
Hospital Charge Code	H3200624
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$637.56
Rate for Payer: AlohaCare Medicaid	$322.00
Rate for Payer: AlohaCare Medicare	$579.60
Rate for Payer: Cash Price	$418.60
Rate for Payer: Cash Price	$418.60
Rate for Payer: Devoted Health Medicare	$637.56
Rate for Payer: Hawaii Medical Service Association ABD	$21.96
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$579.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$547.40
Rate for Payer: Humana Medicare	$579.60
Rate for Payer: Kaiser Permanente Commercial	$579.60
Rate for Payer: Kaiser Permanente Medicaid	$328.44
Rate for Payer: Kaiser Permanente Medicare	$579.60
Rate for Payer: MDX Hawaii PPO	$624.68
Rate for Payer: Ohana Health Plan Medicaid	$579.60
Rate for Payer: Ohana Health Plan Medicare	$579.60
Rate for Payer: UnitedHealthcare Medicaid	$21.96
Rate for Payer: UnitedHealthcare Medicare	$579.60
Rate for Payer: University Health Alliance Commercial	$78.55

HCHG PELVIS JUDET, MIN 3 VIEWS

Facility

$644.00

Service Code	HCPCS 72190
Hospital Charge Code	H3200624
Hospital Revenue Code	320
Min. Negotiated Rate	$547.40
Max. Negotiated Rate	$624.68
Rate for Payer: Cash Price	$418.60
Rate for Payer: Health Management Network Commercial	$547.40
Rate for Payer: Kaiser Permanente Commercial	$579.60
Rate for Payer: MDX Hawaii PPO	$624.68

HCHG PEP MASK INIT

Facility

$413.00

Service Code	HCPCS 94667
Hospital Charge Code	H4120320
Hospital Revenue Code	412
Min. Negotiated Rate	$351.05
Max. Negotiated Rate	$400.61
Rate for Payer: Cash Price	$268.45
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61

HCHG PEP MASK INIT

Facility

$413.00

Service Code	HCPCS 94667
Hospital Charge Code	H4120320
Hospital Revenue Code	412
Min. Negotiated Rate	$20.34
Max. Negotiated Rate	$408.87
Rate for Payer: AlohaCare Medicaid	$206.50
Rate for Payer: AlohaCare Medicare	$371.70
Rate for Payer: Cash Price	$268.45
Rate for Payer: Cash Price	$268.45
Rate for Payer: Devoted Health Medicare	$408.87
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$371.70
Rate for Payer: Hawaii Western Management Group Commercial	$392.35
Rate for Payer: Health Management Network Commercial	$351.05
Rate for Payer: Humana Medicare	$371.70
Rate for Payer: Kaiser Permanente Commercial	$371.70
Rate for Payer: Kaiser Permanente Medicaid	$210.63
Rate for Payer: Kaiser Permanente Medicare	$371.70
Rate for Payer: MDX Hawaii PPO	$400.61
Rate for Payer: Ohana Health Plan Medicaid	$371.70
Rate for Payer: Ohana Health Plan Medicare	$371.70
Rate for Payer: UnitedHealthcare Medicaid	$20.34
Rate for Payer: UnitedHealthcare Medicare	$371.70
Rate for Payer: University Health Alliance Commercial	$301.04

HCHG PEP MASK THERAPY SUBSEQ

Facility

$250.00

Service Code	HCPCS 94668
Hospital Charge Code	H4120322
Hospital Revenue Code	412
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$247.50
Rate for Payer: AlohaCare Medicaid	$125.00
Rate for Payer: AlohaCare Medicare	$225.00
Rate for Payer: Cash Price	$162.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Devoted Health Medicare	$247.50
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$225.00
Rate for Payer: Hawaii Western Management Group Commercial	$237.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Humana Medicare	$225.00
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: Kaiser Permanente Medicaid	$127.50
Rate for Payer: Kaiser Permanente Medicare	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50
Rate for Payer: Ohana Health Plan Medicaid	$225.00
Rate for Payer: Ohana Health Plan Medicare	$225.00
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$225.00
Rate for Payer: University Health Alliance Commercial	$182.22

HCHG PEP MASK THERAPY SUBSEQ

Facility

$250.00

Service Code	HCPCS 94668
Hospital Charge Code	H4120322
Hospital Revenue Code	412
Min. Negotiated Rate	$212.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Health Management Network Commercial	$212.50
Rate for Payer: Kaiser Permanente Commercial	$225.00
Rate for Payer: MDX Hawaii PPO	$242.50

HCHG PERITONEAL LAVAGE, INCL IMG GUID

Facility

$4,535.00

Service Code	HCPCS 49084
Hospital Charge Code	H4501047
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,489.65
Rate for Payer: AlohaCare Medicaid	$2,267.50
Rate for Payer: AlohaCare Medicare	$4,081.50
Rate for Payer: Cash Price	$2,947.75
Rate for Payer: Cash Price	$2,947.75
Rate for Payer: Devoted Health Medicare	$4,489.65
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	$4,081.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,308.25
Rate for Payer: Health Management Network Commercial	$3,854.75
Rate for Payer: Humana Medicare	$4,081.50
Rate for Payer: Kaiser Permanente Commercial	$4,081.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$4,081.50
Rate for Payer: MDX Hawaii PPO	$4,398.95
Rate for Payer: Ohana Health Plan Medicaid	$4,081.50
Rate for Payer: Ohana Health Plan Medicare	$4,081.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,081.50
Rate for Payer: University Health Alliance Commercial	$3,305.56

HCHG PERITONEAL LAVAGE, INCL IMG GUID

Facility

$4,535.00

Service Code	HCPCS 49084
Hospital Charge Code	H4501047
Hospital Revenue Code	450
Min. Negotiated Rate	$3,854.75
Max. Negotiated Rate	$4,398.95
Rate for Payer: Cash Price	$2,947.75
Rate for Payer: Health Management Network Commercial	$3,854.75
Rate for Payer: Kaiser Permanente Commercial	$4,081.50
Rate for Payer: MDX Hawaii PPO	$4,398.95

HCHG PH-BODY FLD

Facility

$27.00

Service Code	HCPCS 83986
Hospital Charge Code	H3011036
Hospital Revenue Code	301
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

HCHG PH-BODY FLD

Facility

$27.00

Service Code	HCPCS 83986
Hospital Charge Code	H3011036
Hospital Revenue Code	301
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$26.73
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$24.30
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$26.73
Rate for Payer: Hawaii Medical Service Association ABD	$4.95
Rate for Payer: Hawaii Medical Service Association Commercial	$4.47
Rate for Payer: Hawaii Medical Service Association Medicare	$24.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$3.58
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$24.30
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$24.30
Rate for Payer: Ohana Health Plan Medicare	$24.30
Rate for Payer: UnitedHealthcare Medicaid	$4.95
Rate for Payer: UnitedHealthcare Medicare	$24.30
Rate for Payer: University Health Alliance Commercial	$9.25

HCHG PHENOBARBITAL

Facility

$169.00

Service Code	HCPCS 80184
Hospital Charge Code	H3011040
Hospital Revenue Code	301
Min. Negotiated Rate	$143.65
Max. Negotiated Rate	$163.93
Rate for Payer: Cash Price	$109.85
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: MDX Hawaii PPO	$163.93

HCHG PHENOBARBITAL

Facility

$169.00

Service Code	HCPCS 80184
Hospital Charge Code	H3011040
Hospital Revenue Code	301
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$167.31
Rate for Payer: AlohaCare Medicaid	$84.50
Rate for Payer: AlohaCare Medicare	$152.10
Rate for Payer: Cash Price	$109.85
Rate for Payer: Cash Price	$109.85
Rate for Payer: Devoted Health Medicare	$167.31
Rate for Payer: Hawaii Medical Service Association ABD	$15.83
Rate for Payer: Hawaii Medical Service Association Commercial	$19.12
Rate for Payer: Hawaii Medical Service Association Medicare	$152.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.62
Rate for Payer: Hawaii Western Management Group Commercial	$15.30
Rate for Payer: Health Management Network Commercial	$143.65
Rate for Payer: Humana Medicare	$152.10
Rate for Payer: Kaiser Permanente Commercial	$152.10
Rate for Payer: Kaiser Permanente Medicaid	$86.19
Rate for Payer: Kaiser Permanente Medicare	$152.10
Rate for Payer: MDX Hawaii PPO	$163.93
Rate for Payer: Ohana Health Plan Medicaid	$152.10
Rate for Payer: Ohana Health Plan Medicare	$152.10
Rate for Payer: UnitedHealthcare Medicaid	$15.83
Rate for Payer: UnitedHealthcare Medicare	$152.10
Rate for Payer: University Health Alliance Commercial	$29.62

HCHG PH FECES 90

Facility

$27.00

Service Code	HCPCS 83986
Hospital Charge Code	H3011034
Hospital Revenue Code	301
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

HCHG PH FECES 90

Facility

$27.00

Service Code	HCPCS 83986
Hospital Charge Code	H3011034
Hospital Revenue Code	301
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$26.73
Rate for Payer: AlohaCare Medicaid	$13.50
Rate for Payer: AlohaCare Medicare	$24.30
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cash Price	$17.55
Rate for Payer: Devoted Health Medicare	$26.73
Rate for Payer: Hawaii Medical Service Association ABD	$4.95
Rate for Payer: Hawaii Medical Service Association Commercial	$4.47
Rate for Payer: Hawaii Medical Service Association Medicare	$24.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.20
Rate for Payer: Hawaii Western Management Group Commercial	$3.58
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Humana Medicare	$24.30
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: Kaiser Permanente Medicaid	$13.77
Rate for Payer: Kaiser Permanente Medicare	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19
Rate for Payer: Ohana Health Plan Medicaid	$24.30
Rate for Payer: Ohana Health Plan Medicare	$24.30
Rate for Payer: UnitedHealthcare Medicaid	$4.95
Rate for Payer: UnitedHealthcare Medicare	$24.30
Rate for Payer: University Health Alliance Commercial	$9.25

HCHG PHOSPHATYLSERINE IGG AB

Facility

$121.00

Service Code	HCPCS 86148
Hospital Charge Code	H3020674
Hospital Revenue Code	302
Min. Negotiated Rate	$102.85
Max. Negotiated Rate	$117.37
Rate for Payer: Cash Price	$78.65
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$108.90
Rate for Payer: MDX Hawaii PPO	$117.37

Know your out-of-pocket cost for care.

All Charges