Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Add-On Chlamydia Pneumo Amp Prb FSI

Facility

$321.00

Service Code	HCPCS 87486
Hospital Charge Code	8301525
Hospital Revenue Code	306
Min. Negotiated Rate	$29.42
Max. Negotiated Rate	$311.37
Rate for Payer: AlohaCare Medicaid	$160.50
Rate for Payer: AlohaCare Medicare	$160.50
Rate for Payer: Cash Price	$208.65
Rate for Payer: Cash Price	$208.65
Rate for Payer: Devoted Health Medicare	$176.55
Rate for Payer: Hawaii Medical Service Association ABD	$29.42
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$160.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.48
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Humana Medicare	$160.50
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: Kaiser Permanente Medicaid	$163.71
Rate for Payer: Kaiser Permanente Medicare	$160.50
Rate for Payer: MDX Hawaii PPO	$311.37
Rate for Payer: Ohana Health Plan Medicaid	$160.50
Rate for Payer: Ohana Health Plan Medicare	$160.50
Rate for Payer: UnitedHealthcare Medicaid	$29.42
Rate for Payer: UnitedHealthcare Medicare	$160.50
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Chlamydia Pneumo Amp Prb FSI

Facility

$321.00

Service Code	HCPCS 87486
Hospital Charge Code	8301525
Hospital Revenue Code	306
Min. Negotiated Rate	$272.85
Max. Negotiated Rate	$311.37
Rate for Payer: Cash Price	$208.65
Rate for Payer: Health Management Network Commercial	$272.85
Rate for Payer: Kaiser Permanente Commercial	$288.90
Rate for Payer: MDX Hawaii PPO	$311.37

Add-On Creatinine Ur Random KSO FSI

Facility

$269.00

Service Code	HCPCS 82570
Hospital Charge Code	8301519
Hospital Revenue Code	301
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$260.93
Rate for Payer: Cash Price	$174.85
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: Kaiser Permanente Commercial	$242.10
Rate for Payer: MDX Hawaii PPO	$260.93

Add-On Creatinine Ur Random KSO FSI

Facility

$269.00

Service Code	HCPCS 82570
Hospital Charge Code	8301519
Hospital Revenue Code	301
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$260.93
Rate for Payer: AlohaCare Medicaid	$134.50
Rate for Payer: AlohaCare Medicare	$134.50
Rate for Payer: Cash Price	$174.85
Rate for Payer: Cash Price	$174.85
Rate for Payer: Devoted Health Medicare	$147.95
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	$134.50
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	$228.65
Rate for Payer: Humana Medicare	$134.50
Rate for Payer: Kaiser Permanente Commercial	$242.10
Rate for Payer: Kaiser Permanente Medicaid	$137.19
Rate for Payer: Kaiser Permanente Medicare	$134.50
Rate for Payer: MDX Hawaii PPO	$260.93
Rate for Payer: Ohana Health Plan Medicaid	$134.50
Rate for Payer: Ohana Health Plan Medicare	$134.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$134.50
Rate for Payer: University Health Alliance Commercial	$13.38

Add-On Culture CMV Shell Vial SO

Facility

$243.00

Service Code	HCPCS 87254
Hospital Charge Code	8301530
Hospital Revenue Code	306
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$235.71
Rate for Payer: Cash Price	$157.95
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: MDX Hawaii PPO	$235.71

Add-On Culture CMV Shell Vial SO

Facility

$243.00

Service Code	HCPCS 87254
Hospital Charge Code	8301530
Hospital Revenue Code	306
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$235.71
Rate for Payer: AlohaCare Medicaid	$121.50
Rate for Payer: AlohaCare Medicare	$121.50
Rate for Payer: Cash Price	$157.95
Rate for Payer: Cash Price	$157.95
Rate for Payer: Devoted Health Medicare	$133.65
Rate for Payer: Hawaii Medical Service Association ABD	$16.39
Rate for Payer: Hawaii Medical Service Association Commercial	$24.45
Rate for Payer: Hawaii Medical Service Association Medicare	$121.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.20
Rate for Payer: Hawaii Western Management Group Commercial	$19.56
Rate for Payer: Health Management Network Commercial	$206.55
Rate for Payer: Humana Medicare	$121.50
Rate for Payer: Kaiser Permanente Commercial	$218.70
Rate for Payer: Kaiser Permanente Medicaid	$123.93
Rate for Payer: Kaiser Permanente Medicare	$121.50
Rate for Payer: MDX Hawaii PPO	$235.71
Rate for Payer: Ohana Health Plan Medicaid	$121.50
Rate for Payer: Ohana Health Plan Medicare	$121.50
Rate for Payer: UnitedHealthcare Medicaid	$16.39
Rate for Payer: UnitedHealthcare Medicare	$121.50
Rate for Payer: University Health Alliance Commercial	$50.54

Add-On Culture Stool Campy KSO FSI

Facility

$139.00

Service Code	HCPCS 87899
Hospital Charge Code	8301528
Hospital Revenue Code	306
Min. Negotiated Rate	$16.07
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$20.09
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$16.07
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Add-On Culture Stool Campy KSO FSI

Facility

$139.00

Service Code	HCPCS 87899
Hospital Charge Code	8301528
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Add-On Enterovirus Pcr Plasma SO FSI

Facility

$392.00

Service Code	HCPCS 87498
Hospital Charge Code	8301521
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$49.04
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.49
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$49.04
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Enterovirus Pcr Plasma SO FSI

Facility

$392.00

Service Code	HCPCS 87498
Hospital Charge Code	8301521
Hospital Revenue Code	306
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Add-On Glucose Tolerance>3 Spec FSI

Facility

$49.00

Service Code	HCPCS 82952
Hospital Charge Code	8301513
Hospital Revenue Code	301
Min. Negotiated Rate	$3.92
Max. Negotiated Rate	$47.53
Rate for Payer: AlohaCare Medicaid	$24.50
Rate for Payer: AlohaCare Medicare	$24.50
Rate for Payer: Cash Price	$31.85
Rate for Payer: Cash Price	$31.85
Rate for Payer: Devoted Health Medicare	$26.95
Rate for Payer: Hawaii Medical Service Association ABD	$5.42
Rate for Payer: Hawaii Medical Service Association Commercial	$4.90
Rate for Payer: Hawaii Medical Service Association Medicare	$24.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.69
Rate for Payer: Hawaii Western Management Group Commercial	$3.92
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Humana Medicare	$24.50
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: Kaiser Permanente Medicaid	$24.99
Rate for Payer: Kaiser Permanente Medicare	$24.50
Rate for Payer: MDX Hawaii PPO	$47.53
Rate for Payer: Ohana Health Plan Medicaid	$24.50
Rate for Payer: Ohana Health Plan Medicare	$24.50
Rate for Payer: UnitedHealthcare Medicaid	$5.42
Rate for Payer: UnitedHealthcare Medicare	$24.50
Rate for Payer: University Health Alliance Commercial	$10.14

Add-On Glucose Tolerance>3 Spec FSI

Facility

$49.00

Service Code	HCPCS 82952
Hospital Charge Code	8301513
Hospital Revenue Code	301
Min. Negotiated Rate	$41.65
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$31.85
Rate for Payer: Health Management Network Commercial	$41.65
Rate for Payer: Kaiser Permanente Commercial	$44.10
Rate for Payer: MDX Hawaii PPO	$47.53

Add-On Herpes Simplex 2 Ab SO FSI

Facility

$218.00

Service Code	HCPCS 86696
Hospital Charge Code	8301510
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$211.46
Rate for Payer: AlohaCare Medicaid	$109.00
Rate for Payer: AlohaCare Medicare	$109.00
Rate for Payer: Cash Price	$141.70
Rate for Payer: Cash Price	$141.70
Rate for Payer: Devoted Health Medicare	$119.90
Rate for Payer: Hawaii Medical Service Association ABD	$27.05
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$109.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.40
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Humana Medicare	$109.00
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: Kaiser Permanente Medicaid	$111.18
Rate for Payer: Kaiser Permanente Medicare	$109.00
Rate for Payer: MDX Hawaii PPO	$211.46
Rate for Payer: Ohana Health Plan Medicaid	$109.00
Rate for Payer: Ohana Health Plan Medicare	$109.00
Rate for Payer: UnitedHealthcare Medicaid	$27.05
Rate for Payer: UnitedHealthcare Medicare	$109.00
Rate for Payer: University Health Alliance Commercial	$50.04

Add-On Herpes Simplex 2 Ab SO FSI

Facility

$218.00

Service Code	HCPCS 86696
Hospital Charge Code	8301510
Hospital Revenue Code	302
Min. Negotiated Rate	$185.30
Max. Negotiated Rate	$211.46
Rate for Payer: Cash Price	$141.70
Rate for Payer: Health Management Network Commercial	$185.30
Rate for Payer: Kaiser Permanente Commercial	$196.20
Rate for Payer: MDX Hawaii PPO	$211.46

Add-On HSV 2 AMP Prob CSF/Swab FSI

Facility

$392.00

Service Code	HCPCS 87529
Hospital Charge Code	8301514
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$380.24
Rate for Payer: AlohaCare Medicaid	$196.00
Rate for Payer: AlohaCare Medicare	$196.00
Rate for Payer: Cash Price	$254.80
Rate for Payer: Cash Price	$254.80
Rate for Payer: Devoted Health Medicare	$215.60
Rate for Payer: Hawaii Medical Service Association ABD	$46.44
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$196.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.76
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Humana Medicare	$196.00
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: Kaiser Permanente Medicare	$196.00
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: Ohana Health Plan Medicaid	$196.00
Rate for Payer: Ohana Health Plan Medicare	$196.00
Rate for Payer: UnitedHealthcare Medicaid	$46.44
Rate for Payer: UnitedHealthcare Medicare	$196.00
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On HSV 2 AMP Prob CSF/Swab FSI

Facility

$392.00

Service Code	HCPCS 87529
Hospital Charge Code	8301514
Hospital Revenue Code	306
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$254.80
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$352.80
Rate for Payer: MDX Hawaii PPO	$380.24

Add-On Hsv 6 Amp Probe FSI

Facility

$303.00

Service Code	HCPCS 87532
Hospital Charge Code	8301520
Hospital Revenue Code	306
Min. Negotiated Rate	$257.55
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$196.95
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Kaiser Permanente Commercial	$272.70
Rate for Payer: MDX Hawaii PPO	$293.91

Add-On Hsv 6 Amp Probe FSI

Facility

$303.00

Service Code	HCPCS 87532
Hospital Charge Code	8301520
Hospital Revenue Code	306
Min. Negotiated Rate	$29.42
Max. Negotiated Rate	$293.91
Rate for Payer: AlohaCare Medicaid	$151.50
Rate for Payer: AlohaCare Medicare	$151.50
Rate for Payer: Cash Price	$196.95
Rate for Payer: Cash Price	$196.95
Rate for Payer: Devoted Health Medicare	$166.65
Rate for Payer: Hawaii Medical Service Association ABD	$29.42
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$151.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.48
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Humana Medicare	$151.50
Rate for Payer: Kaiser Permanente Commercial	$272.70
Rate for Payer: Kaiser Permanente Medicaid	$154.53
Rate for Payer: Kaiser Permanente Medicare	$151.50
Rate for Payer: MDX Hawaii PPO	$293.91
Rate for Payer: Ohana Health Plan Medicaid	$151.50
Rate for Payer: Ohana Health Plan Medicare	$151.50
Rate for Payer: UnitedHealthcare Medicaid	$29.42
Rate for Payer: UnitedHealthcare Medicare	$151.50
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Inf Ag Amp Probe Each FSI

Facility

$303.00

Service Code	HCPCS 87798
Hospital Charge Code	8301522
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$293.91
Rate for Payer: AlohaCare Medicaid	$151.50
Rate for Payer: AlohaCare Medicare	$151.50
Rate for Payer: Cash Price	$196.95
Rate for Payer: Cash Price	$196.95
Rate for Payer: Devoted Health Medicare	$166.65
Rate for Payer: Hawaii Medical Service Association ABD	$48.50
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$151.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Humana Medicare	$151.50
Rate for Payer: Kaiser Permanente Commercial	$272.70
Rate for Payer: Kaiser Permanente Medicaid	$154.53
Rate for Payer: Kaiser Permanente Medicare	$151.50
Rate for Payer: MDX Hawaii PPO	$293.91
Rate for Payer: Ohana Health Plan Medicaid	$151.50
Rate for Payer: Ohana Health Plan Medicare	$151.50
Rate for Payer: UnitedHealthcare Medicaid	$48.50
Rate for Payer: UnitedHealthcare Medicare	$151.50
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Inf Ag Amp Probe Each FSI

Facility

$303.00

Service Code	HCPCS 87798
Hospital Charge Code	8301522
Hospital Revenue Code	306
Min. Negotiated Rate	$257.55
Max. Negotiated Rate	$293.91
Rate for Payer: Cash Price	$196.95
Rate for Payer: Health Management Network Commercial	$257.55
Rate for Payer: Kaiser Permanente Commercial	$272.70
Rate for Payer: MDX Hawaii PPO	$293.91

Add-On Infect Agnt ID Dir Obs SO FSI

Facility

$124.00

Service Code	HCPCS 87046
Hospital Charge Code	8301527
Hospital Revenue Code	306
Min. Negotiated Rate	$7.91
Max. Negotiated Rate	$120.28
Rate for Payer: AlohaCare Medicaid	$62.00
Rate for Payer: AlohaCare Medicare	$62.00
Rate for Payer: Cash Price	$80.60
Rate for Payer: Cash Price	$80.60
Rate for Payer: Devoted Health Medicare	$68.20
Rate for Payer: Hawaii Medical Service Association ABD	$7.91
Rate for Payer: Hawaii Medical Service Association Commercial	$11.80
Rate for Payer: Hawaii Medical Service Association Medicare	$62.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.65
Rate for Payer: Hawaii Western Management Group Commercial	$9.44
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Humana Medicare	$62.00
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: Kaiser Permanente Medicaid	$63.24
Rate for Payer: Kaiser Permanente Medicare	$62.00
Rate for Payer: MDX Hawaii PPO	$120.28
Rate for Payer: Ohana Health Plan Medicaid	$62.00
Rate for Payer: Ohana Health Plan Medicare	$62.00
Rate for Payer: UnitedHealthcare Medicaid	$7.91
Rate for Payer: UnitedHealthcare Medicare	$62.00
Rate for Payer: University Health Alliance Commercial	$24.38

Add-On Infect Agnt ID Dir Obs SO FSI

Facility

$124.00

Service Code	HCPCS 87046
Hospital Charge Code	8301527
Hospital Revenue Code	306
Min. Negotiated Rate	$105.40
Max. Negotiated Rate	$120.28
Rate for Payer: Cash Price	$80.60
Rate for Payer: Health Management Network Commercial	$105.40
Rate for Payer: Kaiser Permanente Commercial	$111.60
Rate for Payer: MDX Hawaii PPO	$120.28

Add-On Influenza Ag Add FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8301515
Hospital Revenue Code	306
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
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	$69.50
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	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$31.01

Add-On Influenza Ag Add FSI

Facility

$139.00

Service Code	HCPCS 87804 QW
Hospital Charge Code	8301515
Hospital Revenue Code	306
Min. Negotiated Rate	$118.15
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83

Add-On Insulin Free SO FSI

Facility

$148.00

Service Code	HCPCS 83527
Hospital Charge Code	8301516
Hospital Revenue Code	301
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: Kaiser Permanente Commercial	$133.20
Rate for Payer: MDX Hawaii PPO	$143.56

Know your out-of-pocket cost for care.

All Charges