Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Bill Only 3 Hr Glucose Tol (Blood)

Facility

$91.00

Hospital Charge Code	12927337
Hospital Revenue Code	301
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$59.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$81.90
Rate for Payer: MDX Hawaii PPO	$88.27

Bill Only 80346 Benzodiazepines,MS,WB/SP RFX

Facility

$162.00

Service Code	HCPCS 80346
Hospital Charge Code	13395378
Hospital Revenue Code	300
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14

Bill Only 80346 Benzodiazepines,MS,WB/SP RFX

Facility

$162.00

Service Code	HCPCS 80346
Hospital Charge Code	13395378
Hospital Revenue Code	300
Min. Negotiated Rate	$25.56
Max. Negotiated Rate	$157.14
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$81.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association ABD	$25.56
Rate for Payer: Hawaii Medical Service Association Medicare	$81.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.84
Rate for Payer: Hawaii Western Management Group Commercial	$153.90
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$81.00
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$81.00
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$81.00
Rate for Payer: Ohana Health Plan Medicare	$81.00
Rate for Payer: UnitedHealthcare Medicare	$81.00
Rate for Payer: University Health Alliance Commercial	$90.72

Bill Only 81015 Urine Micro Only w/ Reflex to C&S

Facility

$12.00

Service Code	HCPCS 81015
Hospital Charge Code	13395393
Hospital Revenue Code	300
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: MDX Hawaii PPO	$11.64

Bill Only 81015 Urine Micro Only w/ Reflex to C&S

Facility

$12.00

Service Code	HCPCS 81015
Hospital Charge Code	13395393
Hospital Revenue Code	300
Min. Negotiated Rate	$3.05
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicare	$6.00
Rate for Payer: Cash Price	$7.80
Rate for Payer: Cash Price	$7.80
Rate for Payer: Devoted Health Medicare	$6.60
Rate for Payer: Hawaii Medical Service Association ABD	$4.20
Rate for Payer: Hawaii Medical Service Association Commercial	$3.81
Rate for Payer: Hawaii Medical Service Association Medicare	$6.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.41
Rate for Payer: Hawaii Western Management Group Commercial	$3.05
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$6.00
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$6.00
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$6.00
Rate for Payer: Ohana Health Plan Medicare	$6.00
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicare	$6.00
Rate for Payer: University Health Alliance Commercial	$7.84

Bill Only 81381 HLA-B*58:01 Genotyping

Facility

$365.00

Service Code	HCPCS 81381
Hospital Charge Code	13395388
Hospital Revenue Code	300
Min. Negotiated Rate	$78.00
Max. Negotiated Rate	$354.05
Rate for Payer: AlohaCare Medicaid	$182.50
Rate for Payer: AlohaCare Medicare	$182.50
Rate for Payer: Cash Price	$237.25
Rate for Payer: Cash Price	$237.25
Rate for Payer: Devoted Health Medicare	$200.75
Rate for Payer: Hawaii Medical Service Association Commercial	$212.38
Rate for Payer: Hawaii Medical Service Association Medicare	$182.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$126.60
Rate for Payer: Hawaii Western Management Group Commercial	$169.90
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Humana Medicare	$182.50
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: Kaiser Permanente Medicaid	$186.15
Rate for Payer: Kaiser Permanente Medicare	$182.50
Rate for Payer: MDX Hawaii PPO	$354.05
Rate for Payer: Ohana Health Plan Medicaid	$182.50
Rate for Payer: Ohana Health Plan Medicare	$182.50
Rate for Payer: UnitedHealthcare Medicaid	$78.00
Rate for Payer: UnitedHealthcare Medicare	$182.50
Rate for Payer: University Health Alliance Commercial	$204.40

Bill Only 81381 HLA-B*58:01 Genotyping

Facility

$365.00

Service Code	HCPCS 81381
Hospital Charge Code	13395388
Hospital Revenue Code	300
Min. Negotiated Rate	$310.25
Max. Negotiated Rate	$354.05
Rate for Payer: Cash Price	$237.25
Rate for Payer: Health Management Network Commercial	$310.25
Rate for Payer: Kaiser Permanente Commercial	$328.50
Rate for Payer: MDX Hawaii PPO	$354.05

Bill Only 82308 Calcitonin

Facility

$159.00

Service Code	HCPCS 82308
Hospital Charge Code	13407400
Hospital Revenue Code	300
Min. Negotiated Rate	$135.15
Max. Negotiated Rate	$154.23
Rate for Payer: Cash Price	$103.35
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: MDX Hawaii PPO	$154.23

Bill Only 82308 Calcitonin

Facility

$159.00

Service Code	HCPCS 82308
Hospital Charge Code	13407400
Hospital Revenue Code	300
Min. Negotiated Rate	$26.79
Max. Negotiated Rate	$154.23
Rate for Payer: AlohaCare Medicaid	$79.50
Rate for Payer: AlohaCare Medicare	$79.50
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
Rate for Payer: Devoted Health Medicare	$87.45
Rate for Payer: Hawaii Medical Service Association ABD	$37.01
Rate for Payer: Hawaii Medical Service Association Commercial	$33.49
Rate for Payer: Hawaii Medical Service Association Medicare	$79.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$38.86
Rate for Payer: Hawaii Western Management Group Commercial	$26.79
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Humana Medicare	$79.50
Rate for Payer: Kaiser Permanente Commercial	$143.10
Rate for Payer: Kaiser Permanente Medicaid	$81.09
Rate for Payer: Kaiser Permanente Medicare	$79.50
Rate for Payer: MDX Hawaii PPO	$154.23
Rate for Payer: Ohana Health Plan Medicaid	$79.50
Rate for Payer: Ohana Health Plan Medicare	$79.50
Rate for Payer: UnitedHealthcare Medicaid	$37.01
Rate for Payer: UnitedHealthcare Medicare	$79.50
Rate for Payer: University Health Alliance Commercial	$69.21

Bill Only 82365 Pathology - Stone Analysis

Facility

$121.00

Service Code	HCPCS 82365
Hospital Charge Code	13416123
Hospital Revenue Code	300
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$117.37
Rate for Payer: AlohaCare Medicaid	$60.50
Rate for Payer: AlohaCare Medicare	$60.50
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$66.55
Rate for Payer: Hawaii Medical Service Association ABD	$11.44
Rate for Payer: Hawaii Medical Service Association Commercial	$16.12
Rate for Payer: Hawaii Medical Service Association Medicare	$60.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12.01
Rate for Payer: Hawaii Western Management Group Commercial	$12.90
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Humana Medicare	$60.50
Rate for Payer: Kaiser Permanente Commercial	$108.90
Rate for Payer: Kaiser Permanente Medicaid	$61.71
Rate for Payer: Kaiser Permanente Medicare	$60.50
Rate for Payer: MDX Hawaii PPO	$117.37
Rate for Payer: Ohana Health Plan Medicaid	$60.50
Rate for Payer: Ohana Health Plan Medicare	$60.50
Rate for Payer: UnitedHealthcare Medicaid	$11.44
Rate for Payer: UnitedHealthcare Medicare	$60.50
Rate for Payer: University Health Alliance Commercial	$21.40

Bill Only 82365 Pathology - Stone Analysis

Facility

$121.00

Service Code	HCPCS 82365
Hospital Charge Code	13416123
Hospital Revenue Code	300
Min. Negotiated Rate	$102.85
Max. Negotiated Rate	$117.37
Rate for Payer: Cash Price	$78.65
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$108.90
Rate for Payer: MDX Hawaii PPO	$117.37

Bill Only 82570 5-HIAA, 24Hr Urine w/Creatinine

Facility

$87.00

Service Code	HCPCS 82570
Hospital Charge Code	13395376
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$43.50
Rate for Payer: AlohaCare Medicare	$43.50
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$47.85
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	$43.50
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	$73.95
Rate for Payer: Humana Medicare	$43.50
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$43.50
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$43.50
Rate for Payer: Ohana Health Plan Medicare	$43.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$43.50
Rate for Payer: University Health Alliance Commercial	$13.38

Bill Only 82570 5-HIAA, 24Hr Urine w/Creatinine

Facility

$87.00

Service Code	HCPCS 82570
Hospital Charge Code	13395376
Hospital Revenue Code	300
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Kaiser Permanente Commercial	$78.30
Rate for Payer: MDX Hawaii PPO	$84.39

Bill Only 82653 Pancreatic Elastase, Feces

Facility

$140.00

Service Code	HCPCS 82653
Hospital Charge Code	13407408
Hospital Revenue Code	300
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$91.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

Bill Only 82653 Pancreatic Elastase, Feces

Facility

$140.00

Service Code	HCPCS 82653
Hospital Charge Code	13407408
Hospital Revenue Code	300
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$135.80
Rate for Payer: AlohaCare Medicaid	$70.00
Rate for Payer: AlohaCare Medicare	$70.00
Rate for Payer: Cash Price	$91.00
Rate for Payer: Cash Price	$91.00
Rate for Payer: Devoted Health Medicare	$77.00
Rate for Payer: Hawaii Medical Service Association ABD	$23.79
Rate for Payer: Hawaii Medical Service Association Commercial	$28.71
Rate for Payer: Hawaii Medical Service Association Medicare	$70.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.98
Rate for Payer: Hawaii Western Management Group Commercial	$22.97
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Humana Medicare	$70.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicare	$70.00
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: Ohana Health Plan Medicaid	$70.00
Rate for Payer: Ohana Health Plan Medicare	$70.00
Rate for Payer: UnitedHealthcare Medicaid	$13.78
Rate for Payer: UnitedHealthcare Medicare	$70.00
Rate for Payer: University Health Alliance Commercial	$78.40

Bill Only 83021 Hemoglobinopathy Screen w/ Interp

Facility

$39.00

Service Code	HCPCS 83021
Hospital Charge Code	13395386
Hospital Revenue Code	300
Min. Negotiated Rate	$18.06
Max. Negotiated Rate	$46.68
Rate for Payer: AlohaCare Medicaid	$19.50
Rate for Payer: AlohaCare Medicare	$19.50
Rate for Payer: Cash Price	$25.35
Rate for Payer: Cash Price	$25.35
Rate for Payer: Devoted Health Medicare	$21.45
Rate for Payer: Hawaii Medical Service Association ABD	$24.96
Rate for Payer: Hawaii Medical Service Association Commercial	$22.57
Rate for Payer: Hawaii Medical Service Association Medicare	$19.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.21
Rate for Payer: Hawaii Western Management Group Commercial	$18.06
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Humana Medicare	$19.50
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: Kaiser Permanente Medicaid	$19.89
Rate for Payer: Kaiser Permanente Medicare	$19.50
Rate for Payer: MDX Hawaii PPO	$37.83
Rate for Payer: Ohana Health Plan Medicaid	$19.50
Rate for Payer: Ohana Health Plan Medicare	$19.50
Rate for Payer: UnitedHealthcare Medicaid	$24.96
Rate for Payer: UnitedHealthcare Medicare	$19.50
Rate for Payer: University Health Alliance Commercial	$46.68

Bill Only 83021 Hemoglobinopathy Screen w/ Interp

Facility

$39.00

Service Code	HCPCS 83021
Hospital Charge Code	13395386
Hospital Revenue Code	300
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$37.83
Rate for Payer: Cash Price	$25.35
Rate for Payer: Health Management Network Commercial	$33.15
Rate for Payer: Kaiser Permanente Commercial	$35.10
Rate for Payer: MDX Hawaii PPO	$37.83

Bill Only 83519 PTH-Related Protein

Facility

$208.00

Service Code	HCPCS 83519
Hospital Charge Code	13416124
Hospital Revenue Code	300
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$201.76
Rate for Payer: AlohaCare Medicaid	$104.00
Rate for Payer: AlohaCare Medicare	$104.00
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Devoted Health Medicare	$114.40
Rate for Payer: Hawaii Medical Service Association ABD	$18.67
Rate for Payer: Hawaii Medical Service Association Commercial	$23.00
Rate for Payer: Hawaii Medical Service Association Medicare	$104.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.60
Rate for Payer: Hawaii Western Management Group Commercial	$18.40
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Humana Medicare	$104.00
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: Kaiser Permanente Medicare	$104.00
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: Ohana Health Plan Medicaid	$104.00
Rate for Payer: Ohana Health Plan Medicare	$104.00
Rate for Payer: UnitedHealthcare Medicaid	$18.67
Rate for Payer: UnitedHealthcare Medicare	$104.00
Rate for Payer: University Health Alliance Commercial	$34.93

Bill Only 83519 PTH-Related Protein

Facility

$208.00

Service Code	HCPCS 83519
Hospital Charge Code	13416124
Hospital Revenue Code	300
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$135.20
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$187.20
Rate for Payer: MDX Hawaii PPO	$201.76

Bill Only 83520 Glomerular Basement Membr Ab, Qnt

Facility

$156.00

Service Code	HCPCS 83520
Hospital Charge Code	13395384
Hospital Revenue Code	300
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$101.40
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$140.40
Rate for Payer: MDX Hawaii PPO	$151.32

Bill Only 83520 Glomerular Basement Membr Ab, Qnt

Facility

$156.00

Service Code	HCPCS 83520
Hospital Charge Code	13395384
Hospital Revenue Code	300
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$151.32
Rate for Payer: AlohaCare Medicaid	$78.00
Rate for Payer: AlohaCare Medicare	$78.00
Rate for Payer: Cash Price	$101.40
Rate for Payer: Cash Price	$101.40
Rate for Payer: Devoted Health Medicare	$85.80
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	$78.00
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	$132.60
Rate for Payer: Humana Medicare	$78.00
Rate for Payer: Kaiser Permanente Commercial	$140.40
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: Kaiser Permanente Medicare	$78.00
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: Ohana Health Plan Medicaid	$78.00
Rate for Payer: Ohana Health Plan Medicare	$78.00
Rate for Payer: UnitedHealthcare Medicaid	$17.89
Rate for Payer: UnitedHealthcare Medicare	$78.00
Rate for Payer: University Health Alliance Commercial	$33.47

Bill Only 83630 Lactoferrin, Qualitative, Stool

Facility

$49.00

Service Code	HCPCS 83630
Hospital Charge Code	13407407
Hospital Revenue Code	300
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

Bill Only 83630 Lactoferrin, Qualitative, Stool

Facility

$49.00

Service Code	HCPCS 83630
Hospital Charge Code	13407407
Hospital Revenue Code	300
Min. Negotiated Rate	$16.45
Max. Negotiated Rate	$50.73
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	$16.45
Rate for Payer: Hawaii Medical Service Association Commercial	$24.62
Rate for Payer: Hawaii Medical Service Association Medicare	$24.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.68
Rate for Payer: Hawaii Western Management Group Commercial	$19.70
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	$16.45
Rate for Payer: UnitedHealthcare Medicare	$24.50
Rate for Payer: University Health Alliance Commercial	$50.73

Bill Only 83735 Electrolyte & Osmolality Pnl, Fecal

Facility

$111.00

Service Code	HCPCS 83735
Hospital Charge Code	13395381
Hospital Revenue Code	300
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$107.67
Rate for Payer: AlohaCare Medicaid	$55.50
Rate for Payer: AlohaCare Medicare	$55.50
Rate for Payer: Cash Price	$72.15
Rate for Payer: Cash Price	$72.15
Rate for Payer: Devoted Health Medicare	$61.05
Rate for Payer: Hawaii Medical Service Association ABD	$9.26
Rate for Payer: Hawaii Medical Service Association Commercial	$8.38
Rate for Payer: Hawaii Medical Service Association Medicare	$55.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9.72
Rate for Payer: Hawaii Western Management Group Commercial	$6.70
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Humana Medicare	$55.50
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: Kaiser Permanente Medicaid	$56.61
Rate for Payer: Kaiser Permanente Medicare	$55.50
Rate for Payer: MDX Hawaii PPO	$107.67
Rate for Payer: Ohana Health Plan Medicaid	$55.50
Rate for Payer: Ohana Health Plan Medicare	$55.50
Rate for Payer: UnitedHealthcare Medicaid	$9.26
Rate for Payer: UnitedHealthcare Medicare	$55.50
Rate for Payer: University Health Alliance Commercial	$17.32

Bill Only 83735 Electrolyte & Osmolality Pnl, Fecal

Facility

$111.00

Service Code	HCPCS 83735
Hospital Charge Code	13395381
Hospital Revenue Code	300
Min. Negotiated Rate	$94.35
Max. Negotiated Rate	$107.67
Rate for Payer: Cash Price	$72.15
Rate for Payer: Health Management Network Commercial	$94.35
Rate for Payer: Kaiser Permanente Commercial	$99.90
Rate for Payer: MDX Hawaii PPO	$107.67

Know your out-of-pocket cost for care.

All Charges