Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Add-On Insulin Free SO FSI

Facility

$148.00

Service Code	HCPCS 83527
Hospital Charge Code	8301516
Hospital Revenue Code	301
Min. Negotiated Rate	$10.85
Max. Negotiated Rate	$143.56
Rate for Payer: AlohaCare Medicaid	$74.00
Rate for Payer: AlohaCare Medicare	$74.00
Rate for Payer: Cash Price	$96.20
Rate for Payer: Cash Price	$96.20
Rate for Payer: Devoted Health Medicare	$81.40
Rate for Payer: Hawaii Medical Service Association ABD	$10.85
Rate for Payer: Hawaii Medical Service Association Commercial	$16.19
Rate for Payer: Hawaii Medical Service Association Medicare	$74.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$12.95
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Humana Medicare	$74.00
Rate for Payer: Kaiser Permanente Commercial	$133.20
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: Kaiser Permanente Medicare	$74.00
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: Ohana Health Plan Medicaid	$74.00
Rate for Payer: Ohana Health Plan Medicare	$74.00
Rate for Payer: UnitedHealthcare Medicaid	$10.85
Rate for Payer: UnitedHealthcare Medicare	$74.00
Rate for Payer: University Health Alliance Commercial	$33.47

Add-On Iron Binding Capacity FSI

Facility

$128.00

Service Code	HCPCS 83550
Hospital Charge Code	8301517
Hospital Revenue Code	301
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$124.16
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: MDX Hawaii PPO	$124.16

Add-On Iron Binding Capacity FSI

Facility

$128.00

Service Code	HCPCS 83550
Hospital Charge Code	8301517
Hospital Revenue Code	301
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$124.16
Rate for Payer: AlohaCare Medicaid	$64.00
Rate for Payer: AlohaCare Medicare	$64.00
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Devoted Health Medicare	$70.40
Rate for Payer: Hawaii Medical Service Association ABD	$12.08
Rate for Payer: Hawaii Medical Service Association Commercial	$10.93
Rate for Payer: Hawaii Medical Service Association Medicare	$64.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.68
Rate for Payer: Hawaii Western Management Group Commercial	$8.74
Rate for Payer: Health Management Network Commercial	$108.80
Rate for Payer: Humana Medicare	$64.00
Rate for Payer: Kaiser Permanente Commercial	$115.20
Rate for Payer: Kaiser Permanente Medicaid	$65.28
Rate for Payer: Kaiser Permanente Medicare	$64.00
Rate for Payer: MDX Hawaii PPO	$124.16
Rate for Payer: Ohana Health Plan Medicaid	$64.00
Rate for Payer: Ohana Health Plan Medicare	$64.00
Rate for Payer: UnitedHealthcare Medicaid	$12.08
Rate for Payer: UnitedHealthcare Medicare	$64.00
Rate for Payer: University Health Alliance Commercial	$22.59

Add-On Lambda Lt Chain Quant SO FSI

Facility

$101.00

Service Code	HCPCS 83883
Hospital Charge Code	8301509
Hospital Revenue Code	301
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$97.97
Rate for Payer: AlohaCare Medicaid	$50.50
Rate for Payer: AlohaCare Medicare	$50.50
Rate for Payer: Cash Price	$65.65
Rate for Payer: Cash Price	$65.65
Rate for Payer: Devoted Health Medicare	$55.55
Rate for Payer: Hawaii Medical Service Association ABD	$18.79
Rate for Payer: Hawaii Medical Service Association Commercial	$17.00
Rate for Payer: Hawaii Medical Service Association Medicare	$50.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.73
Rate for Payer: Hawaii Western Management Group Commercial	$13.60
Rate for Payer: Health Management Network Commercial	$85.85
Rate for Payer: Humana Medicare	$50.50
Rate for Payer: Kaiser Permanente Commercial	$90.90
Rate for Payer: Kaiser Permanente Medicaid	$51.51
Rate for Payer: Kaiser Permanente Medicare	$50.50
Rate for Payer: MDX Hawaii PPO	$97.97
Rate for Payer: Ohana Health Plan Medicaid	$50.50
Rate for Payer: Ohana Health Plan Medicare	$50.50
Rate for Payer: UnitedHealthcare Medicaid	$18.79
Rate for Payer: UnitedHealthcare Medicare	$50.50
Rate for Payer: University Health Alliance Commercial	$35.15

Add-On Lambda Lt Chain Quant SO FSI

Facility

$101.00

Service Code	HCPCS 83883
Hospital Charge Code	8301509
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

Add-On Mycoplasma Pneumo Amp Prb FSI

Facility

$352.00

Service Code	HCPCS 87581
Hospital Charge Code	8301526
Hospital Revenue Code	306
Min. Negotiated Rate	$299.20
Max. Negotiated Rate	$341.44
Rate for Payer: Cash Price	$228.80
Rate for Payer: Health Management Network Commercial	$299.20
Rate for Payer: Kaiser Permanente Commercial	$316.80
Rate for Payer: MDX Hawaii PPO	$341.44

Add-On Mycoplasma Pneumo Amp Prb FSI

Facility

$352.00

Service Code	HCPCS 87581
Hospital Charge Code	8301526
Hospital Revenue Code	306
Min. Negotiated Rate	$29.42
Max. Negotiated Rate	$341.44
Rate for Payer: AlohaCare Medicaid	$176.00
Rate for Payer: AlohaCare Medicare	$176.00
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Devoted Health Medicare	$193.60
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	$176.00
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	$299.20
Rate for Payer: Humana Medicare	$176.00
Rate for Payer: Kaiser Permanente Commercial	$316.80
Rate for Payer: Kaiser Permanente Medicaid	$179.52
Rate for Payer: Kaiser Permanente Medicare	$176.00
Rate for Payer: MDX Hawaii PPO	$341.44
Rate for Payer: Ohana Health Plan Medicaid	$176.00
Rate for Payer: Ohana Health Plan Medicare	$176.00
Rate for Payer: UnitedHealthcare Medicaid	$29.42
Rate for Payer: UnitedHealthcare Medicare	$176.00
Rate for Payer: University Health Alliance Commercial	$90.72

Add-On Phosphatidylserine Ab IgG FSI

Facility

$184.00

Service Code	HCPCS 86148
Hospital Charge Code	8335811
Hospital Revenue Code	302
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: MDX Hawaii PPO	$178.48

Add-On Phosphatidylserine Ab IgG FSI

Facility

$184.00

Service Code	HCPCS 86148
Hospital Charge Code	8335811
Hospital Revenue Code	302
Min. Negotiated Rate	$16.07
Max. Negotiated Rate	$178.48
Rate for Payer: AlohaCare Medicaid	$92.00
Rate for Payer: AlohaCare Medicare	$92.00
Rate for Payer: Cash Price	$119.60
Rate for Payer: Cash Price	$119.60
Rate for Payer: Devoted Health Medicare	$101.20
Rate for Payer: Hawaii Medical Service Association ABD	$22.20
Rate for Payer: Hawaii Medical Service Association Commercial	$20.09
Rate for Payer: Hawaii Medical Service Association Medicare	$92.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.31
Rate for Payer: Hawaii Western Management Group Commercial	$16.07
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$92.00
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: Kaiser Permanente Medicare	$92.00
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$92.00
Rate for Payer: Ohana Health Plan Medicare	$92.00
Rate for Payer: UnitedHealthcare Medicaid	$22.20
Rate for Payer: UnitedHealthcare Medicare	$92.00
Rate for Payer: University Health Alliance Commercial	$41.51

Add-On Protein Tot Ur Random KSO

Facility

$63.00

Service Code	HCPCS 84156
Hospital Charge Code	8301529
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$9.47

Add-On Protein Tot Ur Random KSO

Facility

$63.00

Service Code	HCPCS 84156
Hospital Charge Code	8301529
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Add-On PSA Free SO FSI

Facility

$212.00

Service Code	HCPCS 84154
Hospital Charge Code	8301512
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$205.64
Rate for Payer: AlohaCare Medicaid	$106.00
Rate for Payer: AlohaCare Medicare	$106.00
Rate for Payer: Cash Price	$137.80
Rate for Payer: Cash Price	$137.80
Rate for Payer: Devoted Health Medicare	$116.60
Rate for Payer: Hawaii Medical Service Association ABD	$25.42
Rate for Payer: Hawaii Medical Service Association Commercial	$22.99
Rate for Payer: Hawaii Medical Service Association Medicare	$106.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.69
Rate for Payer: Hawaii Western Management Group Commercial	$18.39
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Humana Medicare	$106.00
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: Kaiser Permanente Medicaid	$108.12
Rate for Payer: Kaiser Permanente Medicare	$106.00
Rate for Payer: MDX Hawaii PPO	$205.64
Rate for Payer: Ohana Health Plan Medicaid	$106.00
Rate for Payer: Ohana Health Plan Medicare	$106.00
Rate for Payer: UnitedHealthcare Medicaid	$25.42
Rate for Payer: UnitedHealthcare Medicare	$106.00
Rate for Payer: University Health Alliance Commercial	$47.55

Add-On PSA Free SO FSI

Facility

$212.00

Service Code	HCPCS 84154
Hospital Charge Code	8301512
Hospital Revenue Code	301
Min. Negotiated Rate	$180.20
Max. Negotiated Rate	$205.64
Rate for Payer: Cash Price	$137.80
Rate for Payer: Health Management Network Commercial	$180.20
Rate for Payer: Kaiser Permanente Commercial	$190.80
Rate for Payer: MDX Hawaii PPO	$205.64

Add-On Smear Complex Spec Stain KSO FSI

Facility

$312.00

Service Code	HCPCS 87209
Hospital Charge Code	8301523
Hospital Revenue Code	306
Min. Negotiated Rate	$265.20
Max. Negotiated Rate	$302.64
Rate for Payer: Cash Price	$202.80
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: MDX Hawaii PPO	$302.64

Add-On Smear Complex Spec Stain KSO FSI

Facility

$312.00

Service Code	HCPCS 87209
Hospital Charge Code	8301523
Hospital Revenue Code	306
Min. Negotiated Rate	$17.57
Max. Negotiated Rate	$302.64
Rate for Payer: AlohaCare Medicaid	$156.00
Rate for Payer: AlohaCare Medicare	$156.00
Rate for Payer: Cash Price	$202.80
Rate for Payer: Cash Price	$202.80
Rate for Payer: Devoted Health Medicare	$171.60
Rate for Payer: Hawaii Medical Service Association ABD	$17.57
Rate for Payer: Hawaii Medical Service Association Commercial	$22.48
Rate for Payer: Hawaii Medical Service Association Medicare	$156.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.82
Rate for Payer: Hawaii Western Management Group Commercial	$17.98
Rate for Payer: Health Management Network Commercial	$265.20
Rate for Payer: Humana Medicare	$156.00
Rate for Payer: Kaiser Permanente Commercial	$280.80
Rate for Payer: Kaiser Permanente Medicaid	$159.12
Rate for Payer: Kaiser Permanente Medicare	$156.00
Rate for Payer: MDX Hawaii PPO	$302.64
Rate for Payer: Ohana Health Plan Medicaid	$156.00
Rate for Payer: Ohana Health Plan Medicare	$156.00
Rate for Payer: UnitedHealthcare Medicaid	$17.57
Rate for Payer: UnitedHealthcare Medicare	$156.00
Rate for Payer: University Health Alliance Commercial	$46.45

Add-On T Cell Abs Cd4 Cd8 SO FSI

Facility

$440.00

Service Code	HCPCS 86360
Hospital Charge Code	8301518
Hospital Revenue Code	302
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

Add-On T Cell Abs Cd4 Cd8 SO FSI

Facility

$440.00

Service Code	HCPCS 86360
Hospital Charge Code	8301518
Hospital Revenue Code	302
Min. Negotiated Rate	$46.98
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$64.93
Rate for Payer: Hawaii Medical Service Association Commercial	$58.73
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$68.18
Rate for Payer: Hawaii Western Management Group Commercial	$46.98
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$64.93
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$121.45

Add-On Thyroglobulin Ab SO FSI

Facility

$183.00

Service Code	HCPCS 86800
Hospital Charge Code	8301507
Hospital Revenue Code	302
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$118.95
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: MDX Hawaii PPO	$177.51

Add-On Thyroglobulin Ab SO FSI

Facility

$183.00

Service Code	HCPCS 86800
Hospital Charge Code	8301507
Hospital Revenue Code	302
Min. Negotiated Rate	$15.91
Max. Negotiated Rate	$177.51
Rate for Payer: AlohaCare Medicaid	$91.50
Rate for Payer: AlohaCare Medicare	$91.50
Rate for Payer: Cash Price	$118.95
Rate for Payer: Cash Price	$118.95
Rate for Payer: Devoted Health Medicare	$100.65
Rate for Payer: Hawaii Medical Service Association ABD	$21.98
Rate for Payer: Hawaii Medical Service Association Commercial	$19.89
Rate for Payer: Hawaii Medical Service Association Medicare	$91.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.08
Rate for Payer: Hawaii Western Management Group Commercial	$15.91
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Humana Medicare	$91.50
Rate for Payer: Kaiser Permanente Commercial	$164.70
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: Kaiser Permanente Medicare	$91.50
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: Ohana Health Plan Medicaid	$91.50
Rate for Payer: Ohana Health Plan Medicare	$91.50
Rate for Payer: UnitedHealthcare Medicaid	$21.98
Rate for Payer: UnitedHealthcare Medicare	$91.50
Rate for Payer: University Health Alliance Commercial	$41.11

Add-On Toxoplasma Ab IgG FSI

Facility

$165.00

Service Code	HCPCS 86777
Hospital Charge Code	8335808
Hospital Revenue Code	302
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

Add-On Toxoplasma Ab IgG FSI

Facility

$165.00

Service Code	HCPCS 86777
Hospital Charge Code	8335808
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$160.05
Rate for Payer: AlohaCare Medicaid	$82.50
Rate for Payer: AlohaCare Medicare	$82.50
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Devoted Health Medicare	$90.75
Rate for Payer: Hawaii Medical Service Association ABD	$19.89
Rate for Payer: Hawaii Medical Service Association Commercial	$17.99
Rate for Payer: Hawaii Medical Service Association Medicare	$82.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.88
Rate for Payer: Hawaii Western Management Group Commercial	$14.39
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Humana Medicare	$82.50
Rate for Payer: Kaiser Permanente Commercial	$148.50
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: Kaiser Permanente Medicare	$82.50
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: Ohana Health Plan Medicaid	$82.50
Rate for Payer: Ohana Health Plan Medicare	$82.50
Rate for Payer: UnitedHealthcare Medicaid	$19.89
Rate for Payer: UnitedHealthcare Medicare	$82.50
Rate for Payer: University Health Alliance Commercial	$37.20

Add-On Toxoplasma IgM KSO FSI

Facility

$114.00

Service Code	HCPCS 86778
Hospital Charge Code	8301531
Hospital Revenue Code	302
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$110.58
Rate for Payer: AlohaCare Medicaid	$57.00
Rate for Payer: AlohaCare Medicare	$57.00
Rate for Payer: Cash Price	$74.10
Rate for Payer: Cash Price	$74.10
Rate for Payer: Devoted Health Medicare	$62.70
Rate for Payer: Hawaii Medical Service Association ABD	$19.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18.01
Rate for Payer: Hawaii Medical Service Association Medicare	$57.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.90
Rate for Payer: Hawaii Western Management Group Commercial	$14.41
Rate for Payer: Health Management Network Commercial	$96.90
Rate for Payer: Humana Medicare	$57.00
Rate for Payer: Kaiser Permanente Commercial	$102.60
Rate for Payer: Kaiser Permanente Medicaid	$58.14
Rate for Payer: Kaiser Permanente Medicare	$57.00
Rate for Payer: MDX Hawaii PPO	$110.58
Rate for Payer: Ohana Health Plan Medicaid	$57.00
Rate for Payer: Ohana Health Plan Medicare	$57.00
Rate for Payer: UnitedHealthcare Medicaid	$19.90
Rate for Payer: UnitedHealthcare Medicare	$57.00
Rate for Payer: University Health Alliance Commercial	$37.22

Add-On Toxoplasma IgM KSO FSI

Facility

$114.00

Service Code	HCPCS 86778
Hospital Charge Code	8301531
Hospital Revenue Code	302
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

Add On Typhus Fvr Ab IgM FSI

Facility

$218.00

Service Code	HCPCS 86757
Hospital Charge Code	8335777
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	$26.75
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	$28.09
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	$26.75
Rate for Payer: UnitedHealthcare Medicare	$109.00
Rate for Payer: University Health Alliance Commercial	$50.04

Add On Typhus Fvr Ab IgM FSI

Facility

$218.00

Service Code	HCPCS 86757
Hospital Charge Code	8335777
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

Know your out-of-pocket cost for care.

All Charges