Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Allergen Gluten, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117806
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Gluten, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117806
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Goose Feathers, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117807
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Goose Feathers, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117807
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Honey Bee, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117809
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Honey Bee, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117809
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen House Dust (Greer), IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117810
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen House Dust (Greer), IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117810
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen House Dust (H-S), IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117811
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen House Dust (H-S), IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117811
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Johnson Grass, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117812
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Johnson Grass, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117812
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Latex, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117813
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Latex, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117813
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Lobster, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117814
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Lobster, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117814
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Mucor racemosus, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117815
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Mucor racemosus, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117815
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Ovalbumin, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117817
Hospital Revenue Code	302
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

Allergen Ovalbumin, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117817
Hospital Revenue Code	302
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$13.45
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$43.68

Allergen Ovomucoid, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117818
Hospital Revenue Code	302
Min. Negotiated Rate	$13.45
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$24.78
Rate for Payer: Hawaii Medical Service Association Commercial	$22.41
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.02
Rate for Payer: Hawaii Western Management Group Commercial	$17.93
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$13.45
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$43.68

Allergen Ovomucoid, IgE FSI

Facility

$78.00

Service Code	HCPCS 86008
Hospital Charge Code	8117818
Hospital Revenue Code	302
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

Allergen Oyster, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117819
Hospital Revenue Code	302
Min. Negotiated Rate	$126.65
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$96.85
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: MDX Hawaii PPO	$144.53

Allergen Oyster, IgE FSI

Facility

$149.00

Service Code	HCPCS 86003
Hospital Charge Code	8117819
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$144.53
Rate for Payer: AlohaCare Medicaid	$74.50
Rate for Payer: AlohaCare Medicare	$74.50
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Devoted Health Medicare	$81.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.22
Rate for Payer: Hawaii Medical Service Association Commercial	$6.53
Rate for Payer: Hawaii Medical Service Association Medicare	$74.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.58
Rate for Payer: Hawaii Western Management Group Commercial	$5.22
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Humana Medicare	$74.50
Rate for Payer: Kaiser Permanente Commercial	$134.10
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicare	$74.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: Ohana Health Plan Medicaid	$74.50
Rate for Payer: Ohana Health Plan Medicare	$74.50
Rate for Payer: UnitedHealthcare Medicaid	$7.22
Rate for Payer: UnitedHealthcare Medicare	$74.50
Rate for Payer: University Health Alliance Commercial	$13.51

Allergen Pacific Allergens

Facility

$146.00

Service Code	HCPCS 86003
Hospital Charge Code	8301849
Hospital Revenue Code	301
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: Kaiser Permanente Commercial	$131.40
Rate for Payer: MDX Hawaii PPO	$141.62

Know your out-of-pocket cost for care.

All Charges