Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG ASPERGILLUS AG EIA 90

Facility

$148.00

Service Code	HCPCS 87305
Hospital Charge Code	H3060711
Hospital Revenue Code	306
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$96.20
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: MDX Hawaii PPO	$143.56

HCHG ASPERGILLUS AG EIA 90

Facility

$148.00

Service Code	HCPCS 87305
Hospital Charge Code	H3060711
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$143.56
Rate for Payer: AlohaCare Medicaid	$11.98
Rate for Payer: AlohaCare Medicare	$11.98
Rate for Payer: Cash Price	$96.20
Rate for Payer: Cash Price	$96.20
Rate for Payer: Devoted Health Medicare	$13.18
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$14.97
Rate for Payer: Hawaii Medical Service Association Medicare	$11.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$11.98
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Humana Medicare	$11.98
Rate for Payer: Kaiser Permanente Commercial	$93.24
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: Kaiser Permanente Medicare	$11.98
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: Ohana Health Plan Medicaid	$13.18
Rate for Payer: Ohana Health Plan Medicare	$11.98
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$11.98
Rate for Payer: University Health Alliance Commercial	$31.01

HCHG ASPIRATE PLEURA W/ IMAGING

Facility

$3,214.00

Service Code	HCPCS 32555
Hospital Charge Code	H4501060
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$741.06
Rate for Payer: AlohaCare Medicare	$741.06
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Devoted Health Medicare	$815.17
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$741.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,053.30
Rate for Payer: Health Management Network Commercial	$2,731.90
Rate for Payer: Humana Medicare	$741.06
Rate for Payer: Kaiser Permanente Commercial	$2,024.82
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$741.06
Rate for Payer: MDX Hawaii PPO	$3,117.58
Rate for Payer: Ohana Health Plan Medicaid	$815.17
Rate for Payer: Ohana Health Plan Medicare	$741.06
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$741.06
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG ASPIRATE PLEURA W/ IMAGING

Facility

$3,214.00

Service Code	HCPCS 32555
Hospital Charge Code	H3610574
Hospital Revenue Code	361
Min. Negotiated Rate	$2,731.90
Max. Negotiated Rate	$3,117.58
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Health Management Network Commercial	$2,731.90
Rate for Payer: MDX Hawaii PPO	$3,117.58

HCHG ASPIRATE PLEURA W/ IMAGING

Facility

$3,214.00

Service Code	HCPCS 32555
Hospital Charge Code	H3610574
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$741.06
Rate for Payer: AlohaCare Medicare	$741.06
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Devoted Health Medicare	$815.17
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$741.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$2,731.90
Rate for Payer: Humana Medicare	$741.06
Rate for Payer: Kaiser Permanente Commercial	$2,024.82
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$741.06
Rate for Payer: MDX Hawaii PPO	$3,117.58
Rate for Payer: Ohana Health Plan Medicaid	$815.17
Rate for Payer: Ohana Health Plan Medicare	$741.06
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$741.06
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG ASPIRATE PLEURA W/ IMAGING

Facility

$3,214.00

Service Code	HCPCS 32555
Hospital Charge Code	H4501060
Hospital Revenue Code	450
Min. Negotiated Rate	$2,731.90
Max. Negotiated Rate	$3,117.58
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Health Management Network Commercial	$2,731.90
Rate for Payer: MDX Hawaii PPO	$3,117.58

HCHG ASPIRATE PLEURA W/O IMAGING

Facility

$3,214.00

Service Code	HCPCS 32554
Hospital Charge Code	H4501059
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$741.06
Rate for Payer: AlohaCare Medicare	$741.06
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Devoted Health Medicare	$815.17
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$741.06
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,053.30
Rate for Payer: Health Management Network Commercial	$2,731.90
Rate for Payer: Humana Medicare	$741.06
Rate for Payer: Kaiser Permanente Commercial	$2,024.82
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$741.06
Rate for Payer: MDX Hawaii PPO	$3,117.58
Rate for Payer: Ohana Health Plan Medicaid	$815.17
Rate for Payer: Ohana Health Plan Medicare	$741.06
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$741.06
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG ASPIRATE PLEURA W/O IMAGING

Facility

$3,214.00

Service Code	HCPCS 32554
Hospital Charge Code	H4501059
Hospital Revenue Code	450
Min. Negotiated Rate	$2,731.90
Max. Negotiated Rate	$3,117.58
Rate for Payer: Cash Price	$2,089.10
Rate for Payer: Health Management Network Commercial	$2,731.90
Rate for Payer: MDX Hawaii PPO	$3,117.58

HCHG ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH 90

Facility

$95.00

Service Code	HCPCS 82784
Hospital Charge Code	H3011706
Hospital Revenue Code	301
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$61.75
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: MDX Hawaii PPO	$92.15

HCHG ASSAY OF GAMMAGLOBULIN IGA IGD IGG IGM EACH 90

Facility

$95.00

Service Code	HCPCS 82784
Hospital Charge Code	H3011706
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$92.15
Rate for Payer: AlohaCare Medicaid	$9.30
Rate for Payer: AlohaCare Medicare	$9.30
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Devoted Health Medicare	$10.23
Rate for Payer: Hawaii Medical Service Association ABD	$10.55
Rate for Payer: Hawaii Medical Service Association Commercial	$11.62
Rate for Payer: Hawaii Medical Service Association Medicare	$9.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.08
Rate for Payer: Hawaii Western Management Group Commercial	$9.30
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Humana Medicare	$9.30
Rate for Payer: Kaiser Permanente Commercial	$59.85
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: Kaiser Permanente Medicare	$9.30
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: Ohana Health Plan Medicaid	$10.23
Rate for Payer: Ohana Health Plan Medicare	$9.30
Rate for Payer: UnitedHealthcare Medicaid	$10.55
Rate for Payer: UnitedHealthcare Medicare	$9.30
Rate for Payer: University Health Alliance Commercial	$19.74

HCHG ASSAY SPEC XCP UR&BREATH IA

Facility

$119.00

Service Code	HCPCS 82077
Hospital Charge Code	H3001130
Hospital Revenue Code	300
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$115.43
Rate for Payer: Cash Price	$77.35
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: MDX Hawaii PPO	$115.43

HCHG ASSAY SPEC XCP UR&BREATH IA

Facility

$119.00

Service Code	HCPCS 82077
Hospital Charge Code	H3001130
Hospital Revenue Code	300
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$115.43
Rate for Payer: AlohaCare Medicaid	$17.27
Rate for Payer: AlohaCare Medicare	$17.27
Rate for Payer: Cash Price	$77.35
Rate for Payer: Cash Price	$77.35
Rate for Payer: Devoted Health Medicare	$19.00
Rate for Payer: Hawaii Medical Service Association ABD	$17.89
Rate for Payer: Hawaii Medical Service Association Commercial	$21.59
Rate for Payer: Hawaii Medical Service Association Medicare	$17.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.78
Rate for Payer: Hawaii Western Management Group Commercial	$17.27
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Humana Medicare	$17.27
Rate for Payer: Kaiser Permanente Commercial	$74.97
Rate for Payer: Kaiser Permanente Medicaid	$60.69
Rate for Payer: Kaiser Permanente Medicare	$17.27
Rate for Payer: MDX Hawaii PPO	$115.43
Rate for Payer: Ohana Health Plan Medicaid	$19.00
Rate for Payer: Ohana Health Plan Medicare	$17.27
Rate for Payer: UnitedHealthcare Medicaid	$10.36
Rate for Payer: UnitedHealthcare Medicare	$17.27
Rate for Payer: University Health Alliance Commercial	$86.74

HCHG ASSESS & TREAT PDP INIT EVAL

Facility

$930.00

Service Code	HCPCS 94799
Hospital Charge Code	H4600183
Hospital Revenue Code	460
Min. Negotiated Rate	$790.50
Max. Negotiated Rate	$902.10
Rate for Payer: Cash Price	$604.50
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: MDX Hawaii PPO	$902.10

HCHG ASSESS & TREAT PDP INIT EVAL

Facility

$930.00

Service Code	HCPCS 94799
Hospital Charge Code	H4600183
Hospital Revenue Code	460
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$902.10
Rate for Payer: AlohaCare Medicaid	$152.01
Rate for Payer: AlohaCare Medicare	$152.01
Rate for Payer: Cash Price	$604.50
Rate for Payer: Cash Price	$604.50
Rate for Payer: Devoted Health Medicare	$167.21
Rate for Payer: Hawaii Medical Service Association Commercial	$190.01
Rate for Payer: Hawaii Medical Service Association Medicare	$152.01
Rate for Payer: Hawaii Western Management Group Commercial	$883.50
Rate for Payer: Health Management Network Commercial	$790.50
Rate for Payer: Humana Medicare	$152.01
Rate for Payer: Kaiser Permanente Commercial	$585.90
Rate for Payer: Kaiser Permanente Medicaid	$474.30
Rate for Payer: Kaiser Permanente Medicare	$152.01
Rate for Payer: MDX Hawaii PPO	$902.10
Rate for Payer: Ohana Health Plan Medicaid	$167.21
Rate for Payer: Ohana Health Plan Medicare	$152.01
Rate for Payer: UnitedHealthcare Medicaid	$20.00
Rate for Payer: UnitedHealthcare Medicare	$152.01
Rate for Payer: University Health Alliance Commercial	$677.88

HCHG ATYPICAL P-ANCA TITER

Facility

$88.00

Service Code	HCPCS 86037
Hospital Charge Code	H3021045
Hospital Revenue Code	302
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$85.36
Rate for Payer: Cash Price	$57.20
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: MDX Hawaii PPO	$85.36

HCHG ATYPICAL P-ANCA TITER

Facility

$88.00

Service Code	HCPCS 86037
Hospital Charge Code	H3021045
Hospital Revenue Code	302
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$85.36
Rate for Payer: AlohaCare Medicaid	$12.05
Rate for Payer: AlohaCare Medicare	$12.05
Rate for Payer: Cash Price	$57.20
Rate for Payer: Cash Price	$57.20
Rate for Payer: Devoted Health Medicare	$13.26
Rate for Payer: Hawaii Medical Service Association ABD	$16.66
Rate for Payer: Hawaii Medical Service Association Commercial	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$12.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.49
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$74.80
Rate for Payer: Humana Medicare	$12.05
Rate for Payer: Kaiser Permanente Commercial	$55.44
Rate for Payer: Kaiser Permanente Medicaid	$44.88
Rate for Payer: Kaiser Permanente Medicare	$12.05
Rate for Payer: MDX Hawaii PPO	$85.36
Rate for Payer: Ohana Health Plan Medicaid	$13.26
Rate for Payer: Ohana Health Plan Medicare	$12.05
Rate for Payer: UnitedHealthcare Medicaid	$7.23
Rate for Payer: UnitedHealthcare Medicare	$12.05
Rate for Payer: University Health Alliance Commercial	$64.14

HCHG AU EVOKED OTOACOUSTIC EMISSIONS

Facility

$614.00

Service Code	HCPCS 92587
Hospital Charge Code	H4710118
Hospital Revenue Code	471
Min. Negotiated Rate	$43.74
Max. Negotiated Rate	$595.58
Rate for Payer: AlohaCare Medicaid	$255.08
Rate for Payer: AlohaCare Medicare	$255.08
Rate for Payer: Cash Price	$399.10
Rate for Payer: Cash Price	$399.10
Rate for Payer: Devoted Health Medicare	$280.59
Rate for Payer: Hawaii Medical Service Association ABD	$43.74
Rate for Payer: Hawaii Medical Service Association Commercial	$318.85
Rate for Payer: Hawaii Medical Service Association Medicare	$255.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.25
Rate for Payer: Hawaii Western Management Group Commercial	$583.30
Rate for Payer: Health Management Network Commercial	$521.90
Rate for Payer: Humana Medicare	$255.08
Rate for Payer: Kaiser Permanente Commercial	$386.82
Rate for Payer: Kaiser Permanente Medicaid	$313.14
Rate for Payer: Kaiser Permanente Medicare	$255.08
Rate for Payer: MDX Hawaii PPO	$595.58
Rate for Payer: Ohana Health Plan Medicaid	$280.59
Rate for Payer: Ohana Health Plan Medicare	$255.08
Rate for Payer: UnitedHealthcare Medicaid	$43.74
Rate for Payer: UnitedHealthcare Medicare	$255.08
Rate for Payer: University Health Alliance Commercial	$447.54

HCHG AU EVOKED OTOACOUSTIC EMISSIONS

Facility

$614.00

Service Code	HCPCS 92587
Hospital Charge Code	H4710118
Hospital Revenue Code	471
Min. Negotiated Rate	$521.90
Max. Negotiated Rate	$595.58
Rate for Payer: Cash Price	$399.10
Rate for Payer: Health Management Network Commercial	$521.90
Rate for Payer: MDX Hawaii PPO	$595.58

HCHG AVULSION NAIL PLATE SNGL

Facility

$1,233.00

Service Code	HCPCS 11730
Hospital Charge Code	H4500142
Hospital Revenue Code	450
Min. Negotiated Rate	$1,048.05
Max. Negotiated Rate	$1,196.01
Rate for Payer: Cash Price	$801.45
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: MDX Hawaii PPO	$1,196.01

HCHG AVULSION NAIL PLATE SNGL

Facility

$1,233.00

Service Code	HCPCS 11730
Hospital Charge Code	H4500142
Hospital Revenue Code	450
Min. Negotiated Rate	$237.02
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Cash Price	$801.45
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.35
Rate for Payer: Health Management Network Commercial	$1,048.05
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Commercial	$776.79
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: MDX Hawaii PPO	$1,196.01
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicare	$237.02
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG BARIUM ENEMA DOUBLE CONTRAST

Facility

$1,195.00

Service Code	HCPCS 74280
Hospital Charge Code	H3200138
Hospital Revenue Code	320
Min. Negotiated Rate	$1,015.75
Max. Negotiated Rate	$1,159.15
Rate for Payer: Cash Price	$776.75
Rate for Payer: Health Management Network Commercial	$1,015.75
Rate for Payer: MDX Hawaii PPO	$1,159.15

HCHG BARIUM ENEMA DOUBLE CONTRAST

Facility

$1,195.00

Service Code	HCPCS 74280
Hospital Charge Code	H3200138
Hospital Revenue Code	320
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$1,159.15
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$776.75
Rate for Payer: Cash Price	$776.75
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$89.58
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86.80
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$1,015.75
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$752.85
Rate for Payer: Kaiser Permanente Medicaid	$609.45
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$1,159.15
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$89.58
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$370.48

HCHG BARIUM ENEMA SINGLE CONTRAST

Facility

$1,050.00

Service Code	HCPCS 74270
Hospital Charge Code	H3200202
Hospital Revenue Code	320
Min. Negotiated Rate	$56.53
Max. Negotiated Rate	$1,018.50
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$682.50
Rate for Payer: Cash Price	$682.50
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$56.53
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.14
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$56.53
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$246.75

HCHG BARIUM ENEMA SINGLE CONTRAST

Facility

$1,050.00

Service Code	HCPCS 74270
Hospital Charge Code	H3200202
Hospital Revenue Code	320
Min. Negotiated Rate	$892.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$682.50
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50

HCHG BARTONELLA ANTIBODY

Facility

$125.00

Service Code	HCPCS 86611
Hospital Charge Code	H3021003
Hospital Revenue Code	302
Min. Negotiated Rate	$106.25
Max. Negotiated Rate	$121.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Health Management Network Commercial	$106.25
Rate for Payer: MDX Hawaii PPO	$121.25

Know your out-of-pocket cost for care.

All Charges