Kohala Hospital

All Charges

Charge

Type

Setting

Price

HCHG INDIRECT COOMBS

Facility

$351.00

Service Code	HCPCS 86885
Hospital Charge Code	H3020610
Hospital Revenue Code	302
Min. Negotiated Rate	$298.35
Max. Negotiated Rate	$340.47
Rate for Payer: Cash Price	$228.15
Rate for Payer: Health Management Network Commercial	$298.35
Rate for Payer: Kaiser Permanente Commercial	$315.90
Rate for Payer: MDX Hawaii PPO	$340.47

HCHG INFLUENZA A & B BY ID NOW

Facility

$1,251.00

Service Code	HCPCS 87502
Hospital Charge Code	H3060757
Hospital Revenue Code	306
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$1,238.49
Rate for Payer: AlohaCare Medicaid	$625.50
Rate for Payer: AlohaCare Medicare	$1,125.90
Rate for Payer: Cash Price	$813.15
Rate for Payer: Cash Price	$813.15
Rate for Payer: Devoted Health Medicare	$1,238.49
Rate for Payer: Hawaii Medical Service Association ABD	$119.75
Rate for Payer: Hawaii Medical Service Association Commercial	$119.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117.54
Rate for Payer: Hawaii Western Management Group Commercial	$95.80
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Humana Medicare	$1,125.90
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: Kaiser Permanente Medicaid	$638.01
Rate for Payer: Kaiser Permanente Medicare	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47
Rate for Payer: Ohana Health Plan Medicaid	$1,125.90
Rate for Payer: Ohana Health Plan Medicare	$1,125.90
Rate for Payer: UnitedHealthcare Medicaid	$119.75
Rate for Payer: UnitedHealthcare Medicare	$1,125.90
Rate for Payer: University Health Alliance Commercial	$221.54

HCHG INFLUENZA A & B BY ID NOW

Facility

$1,251.00

Service Code	HCPCS 87502
Hospital Charge Code	H3060757
Hospital Revenue Code	306
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$1,213.47
Rate for Payer: Cash Price	$813.15
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47

HCHG INFLUENZA AG

Facility

$179.00

Service Code	HCPCS 87804
Hospital Charge Code	H3060653
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

HCHG INFLUENZA AG

Facility

$179.00

Service Code	HCPCS 87804
Hospital Charge Code	H3060653
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$177.21
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$161.10
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$177.21
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$161.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$161.10
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$161.10
Rate for Payer: Ohana Health Plan Medicare	$161.10
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$161.10
Rate for Payer: University Health Alliance Commercial	$31.01

HCHG INFLUENZA ASSAY W/OPTIC

Facility

$179.00

Service Code	HCPCS 87804
Hospital Charge Code	H3060774
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

HCHG INFLUENZA ASSAY W/OPTIC

Facility

$179.00

Service Code	HCPCS 87804
Hospital Charge Code	H3060774
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$177.21
Rate for Payer: AlohaCare Medicaid	$89.50
Rate for Payer: AlohaCare Medicare	$161.10
Rate for Payer: Cash Price	$116.35
Rate for Payer: Cash Price	$116.35
Rate for Payer: Devoted Health Medicare	$177.21
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.69
Rate for Payer: Hawaii Medical Service Association Medicare	$161.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.55
Rate for Payer: Health Management Network Commercial	$152.15
Rate for Payer: Humana Medicare	$161.10
Rate for Payer: Kaiser Permanente Commercial	$161.10
Rate for Payer: Kaiser Permanente Medicaid	$91.29
Rate for Payer: Kaiser Permanente Medicare	$161.10
Rate for Payer: MDX Hawaii PPO	$173.63
Rate for Payer: Ohana Health Plan Medicaid	$161.10
Rate for Payer: Ohana Health Plan Medicare	$161.10
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$161.10
Rate for Payer: University Health Alliance Commercial	$31.01

HCHG INFLUENZA DNA AMP PROBE

Facility

$1,251.00

Service Code	HCPCS 87502
Hospital Charge Code	H3060621
Hospital Revenue Code	306
Min. Negotiated Rate	$95.80
Max. Negotiated Rate	$1,238.49
Rate for Payer: AlohaCare Medicaid	$625.50
Rate for Payer: AlohaCare Medicare	$1,125.90
Rate for Payer: Cash Price	$813.15
Rate for Payer: Cash Price	$813.15
Rate for Payer: Devoted Health Medicare	$1,238.49
Rate for Payer: Hawaii Medical Service Association ABD	$119.75
Rate for Payer: Hawaii Medical Service Association Commercial	$119.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,125.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117.54
Rate for Payer: Hawaii Western Management Group Commercial	$95.80
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Humana Medicare	$1,125.90
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: Kaiser Permanente Medicaid	$638.01
Rate for Payer: Kaiser Permanente Medicare	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47
Rate for Payer: Ohana Health Plan Medicaid	$1,125.90
Rate for Payer: Ohana Health Plan Medicare	$1,125.90
Rate for Payer: UnitedHealthcare Medicaid	$119.75
Rate for Payer: UnitedHealthcare Medicare	$1,125.90
Rate for Payer: University Health Alliance Commercial	$221.54

HCHG INFLUENZA DNA AMP PROBE

Facility

$1,251.00

Service Code	HCPCS 87502
Hospital Charge Code	H3060621
Hospital Revenue Code	306
Min. Negotiated Rate	$1,063.35
Max. Negotiated Rate	$1,213.47
Rate for Payer: Cash Price	$813.15
Rate for Payer: Health Management Network Commercial	$1,063.35
Rate for Payer: Kaiser Permanente Commercial	$1,125.90
Rate for Payer: MDX Hawaii PPO	$1,213.47

HCHG INJ ANES AGENT SPHENOPALATINE GANGLION

Facility

$1,721.00

Service Code	HCPCS 64505
Hospital Charge Code	H4501123
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Kaiser Permanente Commercial	$1,548.90
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ ANES AGENT SPHENOPALATINE GANGLION

Facility

$1,721.00

Service Code	HCPCS 64505
Hospital Charge Code	H4501123
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,703.79
Rate for Payer: AlohaCare Medicaid	$860.50
Rate for Payer: AlohaCare Medicare	$1,548.90
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$1,703.79
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	$1,548.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$1,548.90
Rate for Payer: Kaiser Permanente Commercial	$1,548.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,548.90
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$1,548.90
Rate for Payer: Ohana Health Plan Medicare	$1,548.90
Rate for Payer: UnitedHealthcare Medicare	$1,548.90
Rate for Payer: University Health Alliance Commercial	$1,254.44

HCHG INJ ANESTH AGT TRIG NERVE

Facility

$1,721.00

Service Code	HCPCS 64400
Hospital Charge Code	H4500504
Hospital Revenue Code	450
Min. Negotiated Rate	$1,462.85
Max. Negotiated Rate	$1,669.37
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Kaiser Permanente Commercial	$1,548.90
Rate for Payer: MDX Hawaii PPO	$1,669.37

HCHG INJ ANESTH AGT TRIG NERVE

Facility

$1,721.00

Service Code	HCPCS 64400
Hospital Charge Code	H4500504
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$860.50
Rate for Payer: AlohaCare Medicare	$1,548.90
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Cash Price	$1,118.65
Rate for Payer: Devoted Health Medicare	$1,703.79
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	$1,548.90
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.95
Rate for Payer: Health Management Network Commercial	$1,462.85
Rate for Payer: Humana Medicare	$1,548.90
Rate for Payer: Kaiser Permanente Commercial	$1,548.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,548.90
Rate for Payer: MDX Hawaii PPO	$1,669.37
Rate for Payer: Ohana Health Plan Medicaid	$1,548.90
Rate for Payer: Ohana Health Plan Medicare	$1,548.90
Rate for Payer: UnitedHealthcare Medicare	$1,548.90
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ. ANESTHETIC AGENT; GREATER OCCIPITAL NERVE

Facility

$1,695.00

Service Code	HCPCS 64405
Hospital Charge Code	H4501113
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,678.05
Rate for Payer: AlohaCare Medicaid	$847.50
Rate for Payer: AlohaCare Medicare	$1,525.50
Rate for Payer: Cash Price	$1,101.75
Rate for Payer: Cash Price	$1,101.75
Rate for Payer: Devoted Health Medicare	$1,678.05
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	$1,525.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.25
Rate for Payer: Health Management Network Commercial	$1,440.75
Rate for Payer: Humana Medicare	$1,525.50
Rate for Payer: Kaiser Permanente Commercial	$1,525.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,525.50
Rate for Payer: MDX Hawaii PPO	$1,644.15
Rate for Payer: Ohana Health Plan Medicaid	$1,525.50
Rate for Payer: Ohana Health Plan Medicare	$1,525.50
Rate for Payer: UnitedHealthcare Medicare	$1,525.50
Rate for Payer: University Health Alliance Commercial	$1,235.49

HCHG INJ. ANESTHETIC AGENT; GREATER OCCIPITAL NERVE

Facility

$1,695.00

Service Code	HCPCS 64405
Hospital Charge Code	H4501113
Hospital Revenue Code	450
Min. Negotiated Rate	$1,440.75
Max. Negotiated Rate	$1,644.15
Rate for Payer: Cash Price	$1,101.75
Rate for Payer: Health Management Network Commercial	$1,440.75
Rate for Payer: Kaiser Permanente Commercial	$1,525.50
Rate for Payer: MDX Hawaii PPO	$1,644.15

HCHG INJ DIAG/THER SUB LUMB/SAC W/O IMG GDE

Facility

$4,174.00

Service Code	HCPCS 62322
Hospital Charge Code	H3610661
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,132.26
Rate for Payer: AlohaCare Medicaid	$2,087.00
Rate for Payer: AlohaCare Medicare	$3,756.60
Rate for Payer: Cash Price	$2,713.10
Rate for Payer: Cash Price	$2,713.10
Rate for Payer: Cash Price	$2,713.10
Rate for Payer: Devoted Health Medicare	$4,132.26
Rate for Payer: Hawaii Medical Service Association Commercial	$1,129.54
Rate for Payer: Hawaii Medical Service Association Medicare	$3,756.60
Rate for Payer: Health Management Network Commercial	$3,547.90
Rate for Payer: Humana Medicare	$3,756.60
Rate for Payer: Kaiser Permanente Commercial	$3,756.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,756.60
Rate for Payer: MDX Hawaii PPO	$4,048.78
Rate for Payer: Ohana Health Plan Medicaid	$3,756.60
Rate for Payer: Ohana Health Plan Medicare	$3,756.60
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,756.60
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ DIAG/THER SUB LUMB/SAC W/O IMG GDE

Facility

$4,174.00

Service Code	HCPCS 62322
Hospital Charge Code	H3610661
Hospital Revenue Code	361
Min. Negotiated Rate	$3,547.90
Max. Negotiated Rate	$4,048.78
Rate for Payer: Cash Price	$2,713.10
Rate for Payer: Health Management Network Commercial	$3,547.90
Rate for Payer: Kaiser Permanente Commercial	$3,756.60
Rate for Payer: MDX Hawaii PPO	$4,048.78

HCHG INJECT TRIGGER POINTS, =/> 3

Facility

$1,695.00

Service Code	HCPCS 20553
Hospital Charge Code	H4500930
Hospital Revenue Code	450
Min. Negotiated Rate	$1,440.75
Max. Negotiated Rate	$1,644.15
Rate for Payer: Cash Price	$1,101.75
Rate for Payer: Health Management Network Commercial	$1,440.75
Rate for Payer: Kaiser Permanente Commercial	$1,525.50
Rate for Payer: MDX Hawaii PPO	$1,644.15

HCHG INJECT TRIGGER POINTS, =/> 3

Facility

$1,695.00

Service Code	HCPCS 20553
Hospital Charge Code	H4500930
Hospital Revenue Code	450
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$1,678.05
Rate for Payer: AlohaCare Medicaid	$847.50
Rate for Payer: AlohaCare Medicare	$1,525.50
Rate for Payer: Cash Price	$1,101.75
Rate for Payer: Cash Price	$1,101.75
Rate for Payer: Devoted Health Medicare	$1,678.05
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	$1,525.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.25
Rate for Payer: Health Management Network Commercial	$1,440.75
Rate for Payer: Humana Medicare	$1,525.50
Rate for Payer: Kaiser Permanente Commercial	$1,525.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,525.50
Rate for Payer: MDX Hawaii PPO	$1,644.15
Rate for Payer: Ohana Health Plan Medicaid	$1,525.50
Rate for Payer: Ohana Health Plan Medicare	$1,525.50
Rate for Payer: UnitedHealthcare Medicare	$1,525.50
Rate for Payer: University Health Alliance Commercial	$1,235.49

HCHG INJ EPIDURAL BLD/CLOT

Facility

$3,543.00

Service Code	HCPCS 62273
Hospital Charge Code	H4500510
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,771.50
Rate for Payer: AlohaCare Medicare	$3,188.70
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Devoted Health Medicare	$3,507.57
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	$3,188.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.85
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Humana Medicare	$3,188.70
Rate for Payer: Kaiser Permanente Commercial	$3,188.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$3,188.70
Rate for Payer: MDX Hawaii PPO	$3,436.71
Rate for Payer: Ohana Health Plan Medicaid	$3,188.70
Rate for Payer: Ohana Health Plan Medicare	$3,188.70
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$3,188.70
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG INJ EPIDURAL BLD/CLOT

Facility

$3,543.00

Service Code	HCPCS 62273
Hospital Charge Code	H4500510
Hospital Revenue Code	450
Min. Negotiated Rate	$3,011.55
Max. Negotiated Rate	$3,436.71
Rate for Payer: Cash Price	$2,302.95
Rate for Payer: Health Management Network Commercial	$3,011.55
Rate for Payer: Kaiser Permanente Commercial	$3,188.70
Rate for Payer: MDX Hawaii PPO	$3,436.71

HCHG INJ FOR CYSTOGM/VCUG

Facility

$240.00

Service Code	HCPCS 51600
Hospital Charge Code	H3610194
Hospital Revenue Code	361
Min. Negotiated Rate	$32.89
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$120.00
Rate for Payer: AlohaCare Medicare	$216.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Devoted Health Medicare	$237.60
Rate for Payer: Hawaii Medical Service Association Medicare	$216.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Humana Medicare	$216.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: Ohana Health Plan Medicaid	$216.00
Rate for Payer: Ohana Health Plan Medicare	$216.00
Rate for Payer: UnitedHealthcare Medicaid	$32.89
Rate for Payer: UnitedHealthcare Medicare	$216.00
Rate for Payer: University Health Alliance Commercial	$174.94

HCHG INJ FOR CYSTOGM/VCUG

Facility

$240.00

Service Code	HCPCS 51600
Hospital Charge Code	H3610194
Hospital Revenue Code	361
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$216.00
Rate for Payer: MDX Hawaii PPO	$232.80

HCHG INJ FOR RETRO URETHROCYSTOGRAPHY

Facility

$207.00

Service Code	HCPCS 51610
Hospital Charge Code	H3610234
Hospital Revenue Code	361
Min. Negotiated Rate	$40.43
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$186.30
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$204.93
Rate for Payer: Hawaii Medical Service Association Medicare	$186.30
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Humana Medicare	$186.30
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$186.30
Rate for Payer: Ohana Health Plan Medicare	$186.30
Rate for Payer: UnitedHealthcare Medicaid	$40.43
Rate for Payer: UnitedHealthcare Medicare	$186.30
Rate for Payer: University Health Alliance Commercial	$150.88

HCHG INJ FOR RETRO URETHROCYSTOGRAPHY

Facility

$207.00

Service Code	HCPCS 51610
Hospital Charge Code	H3610234
Hospital Revenue Code	361
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

Know your out-of-pocket cost for care.

All Charges