Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG HEPARIN ASSAY LMWH

Facility

$141.00

Service Code	HCPCS 85520
Hospital Charge Code	H3050168
Hospital Revenue Code	305
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: MDX Hawaii PPO	$136.77

HCHG HEPARIN ASSAY UNFRACTIONATED

Facility

$141.00

Service Code	HCPCS 85520
Hospital Charge Code	H3050170
Hospital Revenue Code	305
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$136.77
Rate for Payer: AlohaCare Medicaid	$13.09
Rate for Payer: AlohaCare Medicare	$13.09
Rate for Payer: Cash Price	$91.65
Rate for Payer: Cash Price	$91.65
Rate for Payer: Devoted Health Medicare	$14.40
Rate for Payer: Hawaii Medical Service Association ABD	$15.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.36
Rate for Payer: Hawaii Medical Service Association Medicare	$13.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.60
Rate for Payer: Hawaii Western Management Group Commercial	$13.09
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Humana Medicare	$13.09
Rate for Payer: Kaiser Permanente Commercial	$88.83
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: Kaiser Permanente Medicare	$13.09
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: Ohana Health Plan Medicaid	$14.40
Rate for Payer: Ohana Health Plan Medicare	$13.09
Rate for Payer: UnitedHealthcare Medicaid	$15.81
Rate for Payer: UnitedHealthcare Medicare	$13.09
Rate for Payer: University Health Alliance Commercial	$29.56

HCHG HEPARIN ASSAY UNFRACTIONATED

Facility

$141.00

Service Code	HCPCS 85520
Hospital Charge Code	H3050170
Hospital Revenue Code	305
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: MDX Hawaii PPO	$136.77

HCHG HEPARIN INDUCED AB

Facility

$226.00

Service Code	HCPCS 86022
Hospital Charge Code	H3020550
Hospital Revenue Code	302
Min. Negotiated Rate	$18.37
Max. Negotiated Rate	$219.22
Rate for Payer: AlohaCare Medicaid	$18.37
Rate for Payer: AlohaCare Medicare	$18.37
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$20.21
Rate for Payer: Hawaii Medical Service Association ABD	$25.38
Rate for Payer: Hawaii Medical Service Association Commercial	$22.96
Rate for Payer: Hawaii Medical Service Association Medicare	$18.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.65
Rate for Payer: Hawaii Western Management Group Commercial	$18.37
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Humana Medicare	$18.37
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: Kaiser Permanente Medicare	$18.37
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: Ohana Health Plan Medicaid	$20.21
Rate for Payer: Ohana Health Plan Medicare	$18.37
Rate for Payer: UnitedHealthcare Medicaid	$25.38
Rate for Payer: UnitedHealthcare Medicare	$18.37
Rate for Payer: University Health Alliance Commercial	$47.47

HCHG HEPARIN INDUCED AB

Facility

$226.00

Service Code	HCPCS 86022
Hospital Charge Code	H3020550
Hospital Revenue Code	302
Min. Negotiated Rate	$192.10
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$146.90
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: MDX Hawaii PPO	$219.22

HCHG HEPARIN NEUTRALIZATION

Facility

$106.00

Service Code	HCPCS 85525
Hospital Charge Code	H3050172
Hospital Revenue Code	305
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$102.82
Rate for Payer: AlohaCare Medicaid	$11.84
Rate for Payer: AlohaCare Medicare	$11.84
Rate for Payer: Cash Price	$68.90
Rate for Payer: Cash Price	$68.90
Rate for Payer: Devoted Health Medicare	$13.02
Rate for Payer: Hawaii Medical Service Association ABD	$16.12
Rate for Payer: Hawaii Medical Service Association Commercial	$14.80
Rate for Payer: Hawaii Medical Service Association Medicare	$11.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.93
Rate for Payer: Hawaii Western Management Group Commercial	$11.84
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$11.84
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$11.84
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$13.02
Rate for Payer: Ohana Health Plan Medicare	$11.84
Rate for Payer: UnitedHealthcare Medicaid	$16.12
Rate for Payer: UnitedHealthcare Medicare	$11.84
Rate for Payer: University Health Alliance Commercial	$30.16

HCHG HEPARIN NEUTRALIZATION

Facility

$106.00

Service Code	HCPCS 85525
Hospital Charge Code	H3050172
Hospital Revenue Code	305
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$68.90
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

HCHG HEPATIC FUNCTION

Facility

$141.00

Service Code	HCPCS 80076
Hospital Charge Code	H3010722
Hospital Revenue Code	301
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: MDX Hawaii PPO	$136.77

HCHG HEPATIC FUNCTION

Facility

$141.00

Service Code	HCPCS 80076
Hospital Charge Code	H3010722
Hospital Revenue Code	301
Min. Negotiated Rate	$8.17
Max. Negotiated Rate	$136.77
Rate for Payer: AlohaCare Medicaid	$8.17
Rate for Payer: AlohaCare Medicare	$8.17
Rate for Payer: Cash Price	$91.65
Rate for Payer: Cash Price	$91.65
Rate for Payer: Devoted Health Medicare	$8.99
Rate for Payer: Hawaii Medical Service Association ABD	$11.29
Rate for Payer: Hawaii Medical Service Association Commercial	$10.21
Rate for Payer: Hawaii Medical Service Association Medicare	$8.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.85
Rate for Payer: Hawaii Western Management Group Commercial	$8.17
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Humana Medicare	$8.17
Rate for Payer: Kaiser Permanente Commercial	$88.83
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: Kaiser Permanente Medicare	$8.17
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: Ohana Health Plan Medicaid	$8.99
Rate for Payer: Ohana Health Plan Medicare	$8.17
Rate for Payer: UnitedHealthcare Medicaid	$11.29
Rate for Payer: UnitedHealthcare Medicare	$8.17
Rate for Payer: University Health Alliance Commercial	$21.13

HCHG HEPATITIS A IGG ANTIBODY, SERUM

Facility

$153.00

Service Code	HCPCS 86708
Hospital Charge Code	H3020526
Hospital Revenue Code	302
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$148.41
Rate for Payer: Cash Price	$99.45
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: MDX Hawaii PPO	$148.41

HCHG HEPATITIS A IGG ANTIBODY, SERUM

Facility

$153.00

Service Code	HCPCS 86708
Hospital Charge Code	H3020526
Hospital Revenue Code	302
Min. Negotiated Rate	$12.39
Max. Negotiated Rate	$148.41
Rate for Payer: AlohaCare Medicaid	$12.39
Rate for Payer: AlohaCare Medicare	$12.39
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Devoted Health Medicare	$13.63
Rate for Payer: Hawaii Medical Service Association ABD	$17.12
Rate for Payer: Hawaii Medical Service Association Commercial	$15.49
Rate for Payer: Hawaii Medical Service Association Medicare	$12.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.98
Rate for Payer: Hawaii Western Management Group Commercial	$12.39
Rate for Payer: Health Management Network Commercial	$130.05
Rate for Payer: Humana Medicare	$12.39
Rate for Payer: Kaiser Permanente Commercial	$96.39
Rate for Payer: Kaiser Permanente Medicaid	$78.03
Rate for Payer: Kaiser Permanente Medicare	$12.39
Rate for Payer: MDX Hawaii PPO	$148.41
Rate for Payer: Ohana Health Plan Medicaid	$13.63
Rate for Payer: Ohana Health Plan Medicare	$12.39
Rate for Payer: UnitedHealthcare Medicaid	$17.12
Rate for Payer: UnitedHealthcare Medicare	$12.39
Rate for Payer: University Health Alliance Commercial	$32.02

HCHG HEPATITIS B VIRUS GENOTYPE

Facility

$1,320.00

Service Code	HCPCS 87912
Hospital Charge Code	H3100160
Hospital Revenue Code	306
Min. Negotiated Rate	$212.33
Max. Negotiated Rate	$1,280.40
Rate for Payer: AlohaCare Medicaid	$257.45
Rate for Payer: AlohaCare Medicare	$257.45
Rate for Payer: Cash Price	$858.00
Rate for Payer: Cash Price	$858.00
Rate for Payer: Devoted Health Medicare	$283.19
Rate for Payer: Hawaii Medical Service Association ABD	$256.16
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$257.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$355.58
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$1,122.00
Rate for Payer: Humana Medicare	$257.45
Rate for Payer: Kaiser Permanente Commercial	$831.60
Rate for Payer: Kaiser Permanente Medicaid	$673.20
Rate for Payer: Kaiser Permanente Medicare	$257.45
Rate for Payer: MDX Hawaii PPO	$1,280.40
Rate for Payer: Ohana Health Plan Medicaid	$283.19
Rate for Payer: Ohana Health Plan Medicare	$257.45
Rate for Payer: UnitedHealthcare Medicaid	$212.33
Rate for Payer: UnitedHealthcare Medicare	$257.45
Rate for Payer: University Health Alliance Commercial	$654.68

HCHG HEPATITIS B VIRUS GENOTYPE

Facility

$1,320.00

Service Code	HCPCS 87912
Hospital Charge Code	H3100160
Hospital Revenue Code	306
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$1,280.40
Rate for Payer: Cash Price	$858.00
Rate for Payer: Health Management Network Commercial	$1,122.00
Rate for Payer: MDX Hawaii PPO	$1,280.40

HCHG HEPATITIS DELTA AGENT SO

Facility

$268.00

Service Code	HCPCS 87380
Hospital Charge Code	K3060029
Hospital Revenue Code	306
Min. Negotiated Rate	$13.76
Max. Negotiated Rate	$259.96
Rate for Payer: AlohaCare Medicaid	$18.36
Rate for Payer: AlohaCare Medicare	$18.36
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$20.20
Rate for Payer: Hawaii Medical Service Association ABD	$13.76
Rate for Payer: Hawaii Medical Service Association Commercial	$22.95
Rate for Payer: Hawaii Medical Service Association Medicare	$18.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.67
Rate for Payer: Hawaii Western Management Group Commercial	$18.36
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$18.36
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: Kaiser Permanente Medicare	$18.36
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$20.20
Rate for Payer: Ohana Health Plan Medicare	$18.36
Rate for Payer: UnitedHealthcare Medicaid	$13.76
Rate for Payer: UnitedHealthcare Medicare	$18.36
Rate for Payer: University Health Alliance Commercial	$42.44

HCHG HEPATITIS DELTA AGENT SO

Facility

$268.00

Service Code	HCPCS 87380
Hospital Charge Code	K3060029
Hospital Revenue Code	306
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: MDX Hawaii PPO	$259.96

HCHG HEPATOBILIARY IMG INCL GALLBLADDER WHEN PRESENT W/RX INTERV INC QNT MEAS WHEN PERFORMED

Facility

$2,418.00

Service Code	HCPCS 78227
Hospital Charge Code	H3410376
Hospital Revenue Code	341
Min. Negotiated Rate	$2,055.30
Max. Negotiated Rate	$2,345.46
Rate for Payer: Cash Price	$1,571.70
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: MDX Hawaii PPO	$2,345.46

HCHG HEPATOBILIARY IMG INCL GALLBLADDER WHEN PRESENT W/RX INTERV INC QNT MEAS WHEN PERFORMED

Facility

$2,418.00

Service Code	HCPCS 78227
Hospital Charge Code	H3410376
Hospital Revenue Code	341
Min. Negotiated Rate	$202.87
Max. Negotiated Rate	$2,345.46
Rate for Payer: AlohaCare Medicaid	$641.43
Rate for Payer: AlohaCare Medicare	$641.43
Rate for Payer: Cash Price	$1,571.70
Rate for Payer: Cash Price	$1,571.70
Rate for Payer: Devoted Health Medicare	$705.57
Rate for Payer: Hawaii Medical Service Association ABD	$202.87
Rate for Payer: Hawaii Medical Service Association Commercial	$801.79
Rate for Payer: Hawaii Medical Service Association Medicare	$641.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$384.19
Rate for Payer: Hawaii Western Management Group Commercial	$641.43
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: Humana Medicare	$641.43
Rate for Payer: Kaiser Permanente Commercial	$1,523.34
Rate for Payer: Kaiser Permanente Medicaid	$1,233.18
Rate for Payer: Kaiser Permanente Medicare	$641.43
Rate for Payer: MDX Hawaii PPO	$2,345.46
Rate for Payer: Ohana Health Plan Medicaid	$705.57
Rate for Payer: Ohana Health Plan Medicare	$641.43
Rate for Payer: UnitedHealthcare Medicaid	$202.87
Rate for Payer: UnitedHealthcare Medicare	$641.43
Rate for Payer: University Health Alliance Commercial	$705.77

HCHG HEPATOBILIARY SYSTEM IMAGING, INCL GALLBLADDER WHEN PRESENT

Facility

$2,256.00

Service Code	HCPCS 78226
Hospital Charge Code	H3410375
Hospital Revenue Code	341
Min. Negotiated Rate	$202.87
Max. Negotiated Rate	$2,188.32
Rate for Payer: AlohaCare Medicaid	$472.27
Rate for Payer: AlohaCare Medicare	$472.27
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Devoted Health Medicare	$519.50
Rate for Payer: Hawaii Medical Service Association ABD	$202.87
Rate for Payer: Hawaii Medical Service Association Commercial	$590.34
Rate for Payer: Hawaii Medical Service Association Medicare	$472.27
Rate for Payer: Hawaii Medical Service Association Non-ABD	$276.63
Rate for Payer: Hawaii Western Management Group Commercial	$472.27
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: Humana Medicare	$472.27
Rate for Payer: Kaiser Permanente Commercial	$1,421.28
Rate for Payer: Kaiser Permanente Medicaid	$1,150.56
Rate for Payer: Kaiser Permanente Medicare	$472.27
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: Ohana Health Plan Medicaid	$519.50
Rate for Payer: Ohana Health Plan Medicare	$472.27
Rate for Payer: UnitedHealthcare Medicaid	$202.87
Rate for Payer: UnitedHealthcare Medicare	$472.27
Rate for Payer: University Health Alliance Commercial	$501.63

HCHG HEPATOBILIARY SYSTEM IMAGING, INCL GALLBLADDER WHEN PRESENT

Facility

$2,256.00

Service Code	HCPCS 78226
Hospital Charge Code	H3410375
Hospital Revenue Code	341
Min. Negotiated Rate	$1,917.60
Max. Negotiated Rate	$2,188.32
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: MDX Hawaii PPO	$2,188.32

HCHG HEP B AB QUANT SURFACE

Facility

$146.00

Service Code	HCPCS 86706
Hospital Charge Code	H3020528
Hospital Revenue Code	302
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$141.62
Rate for Payer: AlohaCare Medicaid	$10.74
Rate for Payer: AlohaCare Medicare	$10.74
Rate for Payer: Cash Price	$94.90
Rate for Payer: Cash Price	$94.90
Rate for Payer: Devoted Health Medicare	$11.81
Rate for Payer: Hawaii Medical Service Association ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$10.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Humana Medicare	$10.74
Rate for Payer: Kaiser Permanente Commercial	$91.98
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: Kaiser Permanente Medicare	$10.74
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: Ohana Health Plan Medicaid	$11.81
Rate for Payer: Ohana Health Plan Medicare	$10.74
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$10.74
Rate for Payer: University Health Alliance Commercial	$27.77

HCHG HEP B AB QUANT SURFACE

Facility

$146.00

Service Code	HCPCS 86706
Hospital Charge Code	H3020528
Hospital Revenue Code	302
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: MDX Hawaii PPO	$141.62

HCHG HEP BC AB IGM

Facility

$145.00

Service Code	HCPCS 86705
Hospital Charge Code	H3020534
Hospital Revenue Code	302
Min. Negotiated Rate	$11.77
Max. Negotiated Rate	$140.65
Rate for Payer: AlohaCare Medicaid	$11.77
Rate for Payer: AlohaCare Medicare	$11.77
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$12.95
Rate for Payer: Hawaii Medical Service Association ABD	$16.27
Rate for Payer: Hawaii Medical Service Association Commercial	$14.71
Rate for Payer: Hawaii Medical Service Association Medicare	$11.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.08
Rate for Payer: Hawaii Western Management Group Commercial	$11.77
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Humana Medicare	$11.77
Rate for Payer: Kaiser Permanente Commercial	$91.35
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: Kaiser Permanente Medicare	$11.77
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: Ohana Health Plan Medicaid	$12.95
Rate for Payer: Ohana Health Plan Medicare	$11.77
Rate for Payer: UnitedHealthcare Medicaid	$16.27
Rate for Payer: UnitedHealthcare Medicare	$11.77
Rate for Payer: University Health Alliance Commercial	$30.41

HCHG HEP BC AB IGM

Facility

$145.00

Service Code	HCPCS 86705
Hospital Charge Code	H3020534
Hospital Revenue Code	302
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$94.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: MDX Hawaii PPO	$140.65

HCHG HEP B CORE AB TOT

Facility

$163.00

Service Code	HCPCS 86704
Hospital Charge Code	H3020530
Hospital Revenue Code	302
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$12.05
Rate for Payer: AlohaCare Medicare	$12.05
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
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	$138.55
Rate for Payer: Humana Medicare	$12.05
Rate for Payer: Kaiser Permanente Commercial	$102.69
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$12.05
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$13.26
Rate for Payer: Ohana Health Plan Medicare	$12.05
Rate for Payer: UnitedHealthcare Medicaid	$16.66
Rate for Payer: UnitedHealthcare Medicare	$12.05
Rate for Payer: University Health Alliance Commercial	$31.15

HCHG HEP B CORE AB TOT

Facility

$163.00

Service Code	HCPCS 86704
Hospital Charge Code	H3020530
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: MDX Hawaii PPO	$158.11

Know your out-of-pocket cost for care.

All Charges