Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG ALDOSTERONE-SERUM 90

Facility

$273.00

Service Code	HCPCS 82088
Hospital Charge Code	H3010156
Hospital Revenue Code	301
Min. Negotiated Rate	$232.05
Max. Negotiated Rate	$264.81
Rate for Payer: Cash Price	$177.45
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81

HCHG ALDOSTERONE-SERUM 90

Facility

$273.00

Service Code	HCPCS 82088
Hospital Charge Code	H3010156
Hospital Revenue Code	301
Min. Negotiated Rate	$40.75
Max. Negotiated Rate	$270.27
Rate for Payer: AlohaCare Medicaid	$136.50
Rate for Payer: AlohaCare Medicare	$245.70
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Devoted Health Medicare	$270.27
Rate for Payer: Hawaii Medical Service Association ABD	$56.32
Rate for Payer: Hawaii Medical Service Association Commercial	$50.94
Rate for Payer: Hawaii Medical Service Association Medicare	$245.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.14
Rate for Payer: Hawaii Western Management Group Commercial	$40.75
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Humana Medicare	$245.70
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: Kaiser Permanente Medicaid	$139.23
Rate for Payer: Kaiser Permanente Medicare	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81
Rate for Payer: Ohana Health Plan Medicaid	$245.70
Rate for Payer: Ohana Health Plan Medicare	$245.70
Rate for Payer: UnitedHealthcare Medicaid	$56.32
Rate for Payer: UnitedHealthcare Medicare	$245.70
Rate for Payer: University Health Alliance Commercial	$105.34

HCHG ALKALINE PHOS BONE SP

Facility

$98.00

Service Code	HCPCS 84075
Hospital Charge Code	H3010160
Hospital Revenue Code	301
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

HCHG ALKALINE PHOS BONE SP

Facility

$98.00

Service Code	HCPCS 84075
Hospital Charge Code	H3010160
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$97.02
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$88.20
Rate for Payer: Cash Price	$63.70
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$97.02
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$88.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$88.20
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$88.20
Rate for Payer: Ohana Health Plan Medicare	$88.20
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$88.20
Rate for Payer: University Health Alliance Commercial	$13.38

HCHG ALKALINE PHOS ISOENZYMES 90

Facility

$273.00

Service Code	HCPCS 84080
Hospital Charge Code	H3010162
Hospital Revenue Code	301
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$270.27
Rate for Payer: AlohaCare Medicaid	$136.50
Rate for Payer: AlohaCare Medicare	$245.70
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Devoted Health Medicare	$270.27
Rate for Payer: Hawaii Medical Service Association ABD	$20.44
Rate for Payer: Hawaii Medical Service Association Commercial	$18.48
Rate for Payer: Hawaii Medical Service Association Medicare	$245.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.46
Rate for Payer: Hawaii Western Management Group Commercial	$14.78
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Humana Medicare	$245.70
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: Kaiser Permanente Medicaid	$139.23
Rate for Payer: Kaiser Permanente Medicare	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81
Rate for Payer: Ohana Health Plan Medicaid	$245.70
Rate for Payer: Ohana Health Plan Medicare	$245.70
Rate for Payer: UnitedHealthcare Medicaid	$20.44
Rate for Payer: UnitedHealthcare Medicare	$245.70
Rate for Payer: University Health Alliance Commercial	$38.22

HCHG ALKALINE PHOS ISOENZYMES 90

Facility

$273.00

Service Code	HCPCS 84080
Hospital Charge Code	H3010162
Hospital Revenue Code	301
Min. Negotiated Rate	$232.05
Max. Negotiated Rate	$264.81
Rate for Payer: Cash Price	$177.45
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81

HCHG ALK PHOS ISOENZYMES SO

Facility

$273.00

Service Code	HCPCS 84080
Hospital Charge Code	K3010042
Hospital Revenue Code	301
Min. Negotiated Rate	$14.78
Max. Negotiated Rate	$270.27
Rate for Payer: AlohaCare Medicaid	$136.50
Rate for Payer: AlohaCare Medicare	$245.70
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Devoted Health Medicare	$270.27
Rate for Payer: Hawaii Medical Service Association ABD	$20.44
Rate for Payer: Hawaii Medical Service Association Commercial	$18.48
Rate for Payer: Hawaii Medical Service Association Medicare	$245.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.46
Rate for Payer: Hawaii Western Management Group Commercial	$14.78
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Humana Medicare	$245.70
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: Kaiser Permanente Medicaid	$139.23
Rate for Payer: Kaiser Permanente Medicare	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81
Rate for Payer: Ohana Health Plan Medicaid	$245.70
Rate for Payer: Ohana Health Plan Medicare	$245.70
Rate for Payer: UnitedHealthcare Medicaid	$20.44
Rate for Payer: UnitedHealthcare Medicare	$245.70
Rate for Payer: University Health Alliance Commercial	$38.22

HCHG ALK PHOS ISOENZYMES SO

Facility

$273.00

Service Code	HCPCS 84080
Hospital Charge Code	K3010042
Hospital Revenue Code	301
Min. Negotiated Rate	$232.05
Max. Negotiated Rate	$264.81
Rate for Payer: Cash Price	$177.45
Rate for Payer: Health Management Network Commercial	$232.05
Rate for Payer: Kaiser Permanente Commercial	$245.70
Rate for Payer: MDX Hawaii PPO	$264.81

HCHG ALK PHTASE

Facility

$98.00

Service Code	HCPCS 84075
Hospital Charge Code	H3010158
Hospital Revenue Code	301
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$95.06
Rate for Payer: Cash Price	$63.70
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06

HCHG ALK PHTASE

Facility

$98.00

Service Code	HCPCS 84075
Hospital Charge Code	H3010158
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$97.02
Rate for Payer: AlohaCare Medicaid	$49.00
Rate for Payer: AlohaCare Medicare	$88.20
Rate for Payer: Cash Price	$63.70
Rate for Payer: Cash Price	$63.70
Rate for Payer: Devoted Health Medicare	$97.02
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$88.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Humana Medicare	$88.20
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$49.98
Rate for Payer: Kaiser Permanente Medicare	$88.20
Rate for Payer: MDX Hawaii PPO	$95.06
Rate for Payer: Ohana Health Plan Medicaid	$88.20
Rate for Payer: Ohana Health Plan Medicare	$88.20
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$88.20
Rate for Payer: University Health Alliance Commercial	$13.38

HCHG ALPHA-1 ANTITRYPSIN GENOTYPE - 90

Facility

$268.00

Service Code	HCPCS 81332
Hospital Charge Code	H3100246
Hospital Revenue Code	310
Min. Negotiated Rate	$42.12
Max. Negotiated Rate	$265.32
Rate for Payer: AlohaCare Medicaid	$134.00
Rate for Payer: AlohaCare Medicare	$241.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$265.32
Rate for Payer: Hawaii Medical Service Association Commercial	$54.56
Rate for Payer: Hawaii Medical Service Association Medicare	$241.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$58.43
Rate for Payer: Hawaii Western Management Group Commercial	$43.65
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$241.20
Rate for Payer: Kaiser Permanente Commercial	$241.20
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: Kaiser Permanente Medicare	$241.20
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$241.20
Rate for Payer: Ohana Health Plan Medicare	$241.20
Rate for Payer: UnitedHealthcare Medicaid	$42.12
Rate for Payer: UnitedHealthcare Medicare	$241.20
Rate for Payer: University Health Alliance Commercial	$195.35

HCHG ALPHA-1 ANTITRYPSIN GENOTYPE - 90

Facility

$268.00

Service Code	HCPCS 81332
Hospital Charge Code	H3100246
Hospital Revenue Code	310
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$174.20
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Kaiser Permanente Commercial	$241.20
Rate for Payer: MDX Hawaii PPO	$259.96

HCHG ALPHA-1-ANTITRYPSIN PHENOTYPE

Facility

$101.00

Service Code	HCPCS 82104
Hospital Charge Code	H3011372
Hospital Revenue Code	301
Min. Negotiated Rate	$85.85
Max. Negotiated Rate	$97.97
Rate for Payer: Cash Price	$65.65
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97

HCHG ALPHA-1-ANTITRYPSIN PHENOTYPE

Facility

$101.00

Service Code	HCPCS 82104
Hospital Charge Code	H3011372
Hospital Revenue Code	301
Min. Negotiated Rate	$14.46
Max. Negotiated Rate	$99.99
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$90.90
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$99.99
Rate for Payer: Hawaii Medical Service Association ABD	$19.98
Rate for Payer: Hawaii Medical Service Association Commercial	$18.07
Rate for Payer: Hawaii Medical Service Association Medicare	$90.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.98
Rate for Payer: Hawaii Western Management Group Commercial	$14.46
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$90.90
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$90.90
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$90.90
Rate for Payer: Ohana Health Plan Medicare	$90.90
Rate for Payer: UnitedHealthcare Medicaid	$19.98
Rate for Payer: UnitedHealthcare Medicare	$90.90
Rate for Payer: University Health Alliance Commercial	$37.37

HCHG ALPHA-1 ANTITRYPSIN TOTAL

Facility

$165.00

Service Code	HCPCS 82103
Hospital Charge Code	H3010166
Hospital Revenue Code	301
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$107.25
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: MDX Hawaii PPO	$160.05

HCHG ALPHA-1 ANTITRYPSIN TOTAL

Facility

$165.00

Service Code	HCPCS 82103
Hospital Charge Code	H3010166
Hospital Revenue Code	301
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$163.35
Rate for Payer: AlohaCare Medicaid	$82.50
Rate for Payer: AlohaCare Medicare	$148.50
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Devoted Health Medicare	$163.35
Rate for Payer: Hawaii Medical Service Association ABD	$18.56
Rate for Payer: Hawaii Medical Service Association Commercial	$16.80
Rate for Payer: Hawaii Medical Service Association Medicare	$148.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.49
Rate for Payer: Hawaii Western Management Group Commercial	$13.44
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Humana Medicare	$148.50
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicare	$148.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: Ohana Health Plan Medicaid	$148.50
Rate for Payer: Ohana Health Plan Medicare	$148.50
Rate for Payer: UnitedHealthcare Medicaid	$18.56
Rate for Payer: UnitedHealthcare Medicare	$148.50
Rate for Payer: University Health Alliance Commercial	$34.72

HCHG ALPHA FETOPROTEIN SERUM

Facility

$249.00

Service Code	HCPCS 82105
Hospital Charge Code	K3010022
Hospital Revenue Code	301
Min. Negotiated Rate	$211.65
Max. Negotiated Rate	$241.53
Rate for Payer: Cash Price	$161.85
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Kaiser Permanente Commercial	$224.10
Rate for Payer: MDX Hawaii PPO	$241.53

HCHG ALPHA FETOPROTEIN SERUM

Facility

$249.00

Service Code	HCPCS 82105
Hospital Charge Code	K3010022
Hospital Revenue Code	301
Min. Negotiated Rate	$16.77
Max. Negotiated Rate	$246.51
Rate for Payer: AlohaCare Medicaid	$124.50
Rate for Payer: AlohaCare Medicare	$224.10
Rate for Payer: Cash Price	$161.85
Rate for Payer: Cash Price	$161.85
Rate for Payer: Devoted Health Medicare	$246.51
Rate for Payer: Hawaii Medical Service Association ABD	$23.18
Rate for Payer: Hawaii Medical Service Association Commercial	$20.96
Rate for Payer: Hawaii Medical Service Association Medicare	$224.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.34
Rate for Payer: Hawaii Western Management Group Commercial	$16.77
Rate for Payer: Health Management Network Commercial	$211.65
Rate for Payer: Humana Medicare	$224.10
Rate for Payer: Kaiser Permanente Commercial	$224.10
Rate for Payer: Kaiser Permanente Medicaid	$126.99
Rate for Payer: Kaiser Permanente Medicare	$224.10
Rate for Payer: MDX Hawaii PPO	$241.53
Rate for Payer: Ohana Health Plan Medicaid	$224.10
Rate for Payer: Ohana Health Plan Medicare	$224.10
Rate for Payer: UnitedHealthcare Medicaid	$23.18
Rate for Payer: UnitedHealthcare Medicare	$224.10
Rate for Payer: University Health Alliance Commercial	$43.36

HCHG ALPHA-GLOBIN COMMON MUTATION - 90

Facility

$608.00

Service Code	HCPCS 81257
Hospital Charge Code	H3100159
Hospital Revenue Code	310
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$601.92
Rate for Payer: AlohaCare Medicaid	$304.00
Rate for Payer: AlohaCare Medicare	$547.20
Rate for Payer: Cash Price	$395.20
Rate for Payer: Cash Price	$395.20
Rate for Payer: Devoted Health Medicare	$601.92
Rate for Payer: Hawaii Medical Service Association ABD	$178.42
Rate for Payer: Hawaii Medical Service Association Commercial	$127.83
Rate for Payer: Hawaii Medical Service Association Medicare	$547.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$178.42
Rate for Payer: Hawaii Western Management Group Commercial	$102.26
Rate for Payer: Health Management Network Commercial	$516.80
Rate for Payer: Humana Medicare	$547.20
Rate for Payer: Kaiser Permanente Commercial	$547.20
Rate for Payer: Kaiser Permanente Medicaid	$310.08
Rate for Payer: Kaiser Permanente Medicare	$547.20
Rate for Payer: MDX Hawaii PPO	$589.76
Rate for Payer: Ohana Health Plan Medicaid	$547.20
Rate for Payer: Ohana Health Plan Medicare	$547.20
Rate for Payer: UnitedHealthcare Medicaid	$76.70
Rate for Payer: UnitedHealthcare Medicare	$547.20
Rate for Payer: University Health Alliance Commercial	$338.96

HCHG ALPHA-GLOBIN COMMON MUTATION - 90

Facility

$608.00

Service Code	HCPCS 81257
Hospital Charge Code	H3100159
Hospital Revenue Code	310
Min. Negotiated Rate	$516.80
Max. Negotiated Rate	$589.76
Rate for Payer: Cash Price	$395.20
Rate for Payer: Health Management Network Commercial	$516.80
Rate for Payer: Kaiser Permanente Commercial	$547.20
Rate for Payer: MDX Hawaii PPO	$589.76

HCHG AMIKACIN LEVEL

Facility

$114.00

Service Code	HCPCS 80150
Hospital Charge Code	H3010174
Hospital Revenue Code	301
Min. Negotiated Rate	$15.08
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	$20.83
Rate for Payer: Hawaii Medical Service Association Commercial	$18.85
Rate for Payer: Hawaii Medical Service Association Medicare	$102.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.87
Rate for Payer: Hawaii Western Management Group Commercial	$15.08
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	$20.83
Rate for Payer: UnitedHealthcare Medicare	$102.60
Rate for Payer: University Health Alliance Commercial	$38.96

HCHG AMIKACIN LEVEL

Facility

$114.00

Service Code	HCPCS 80150
Hospital Charge Code	H3010174
Hospital Revenue Code	301
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 AMMONIA

Facility

$242.00

Service Code	HCPCS 82140
Hospital Charge Code	H3010192
Hospital Revenue Code	301
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$239.58
Rate for Payer: AlohaCare Medicaid	$121.00
Rate for Payer: AlohaCare Medicare	$217.80
Rate for Payer: Cash Price	$157.30
Rate for Payer: Cash Price	$157.30
Rate for Payer: Devoted Health Medicare	$239.58
Rate for Payer: Hawaii Medical Service Association ABD	$20.14
Rate for Payer: Hawaii Medical Service Association Commercial	$18.21
Rate for Payer: Hawaii Medical Service Association Medicare	$217.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.15
Rate for Payer: Hawaii Western Management Group Commercial	$14.57
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Humana Medicare	$217.80
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: Kaiser Permanente Medicaid	$123.42
Rate for Payer: Kaiser Permanente Medicare	$217.80
Rate for Payer: MDX Hawaii PPO	$234.74
Rate for Payer: Ohana Health Plan Medicaid	$217.80
Rate for Payer: Ohana Health Plan Medicare	$217.80
Rate for Payer: UnitedHealthcare Medicaid	$20.14
Rate for Payer: UnitedHealthcare Medicare	$217.80
Rate for Payer: University Health Alliance Commercial	$37.67

HCHG AMMONIA

Facility

$242.00

Service Code	HCPCS 82140
Hospital Charge Code	H3010192
Hospital Revenue Code	301
Min. Negotiated Rate	$205.70
Max. Negotiated Rate	$234.74
Rate for Payer: Cash Price	$157.30
Rate for Payer: Health Management Network Commercial	$205.70
Rate for Payer: Kaiser Permanente Commercial	$217.80
Rate for Payer: MDX Hawaii PPO	$234.74

HCHG AMOEBIC AB 90

Facility

$87.00

Service Code	HCPCS 86753
Hospital Charge Code	H3020228
Hospital Revenue Code	302
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

Know your out-of-pocket cost for care.

All Charges