Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

HHSC US Bx Breast Add Lesion RT

Facility

$792.00

Service Code	HCPCS 19084
Hospital Charge Code	8223504
Hospital Revenue Code	361
Min. Negotiated Rate	$75.62
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$396.00
Rate for Payer: AlohaCare Medicare	$396.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cash Price	$514.80
Rate for Payer: Devoted Health Medicare	$435.60
Rate for Payer: Hawaii Medical Service Association Medicare	$396.00
Rate for Payer: Health Management Network Commercial	$673.20
Rate for Payer: Humana Medicare	$396.00
Rate for Payer: Kaiser Permanente Commercial	$712.80
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$396.00
Rate for Payer: MDX Hawaii PPO	$768.24
Rate for Payer: Ohana Health Plan Medicaid	$396.00
Rate for Payer: Ohana Health Plan Medicare	$396.00
Rate for Payer: UnitedHealthcare Medicaid	$75.62
Rate for Payer: UnitedHealthcare Medicare	$396.00
Rate for Payer: University Health Alliance Commercial	$443.52

HHSC US Fluoro Guide Ndl Placement

Facility

$543.00

Service Code	HCPCS 77002
Hospital Charge Code	8224258
Hospital Revenue Code	320
Min. Negotiated Rate	$461.55
Max. Negotiated Rate	$526.71
Rate for Payer: Cash Price	$352.95
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Kaiser Permanente Commercial	$488.70
Rate for Payer: MDX Hawaii PPO	$526.71

HHSC US Fluoro Guide Ndl Placement

Facility

$543.00

Service Code	HCPCS 77002
Hospital Charge Code	8224258
Hospital Revenue Code	320
Min. Negotiated Rate	$38.07
Max. Negotiated Rate	$526.71
Rate for Payer: AlohaCare Medicaid	$271.50
Rate for Payer: AlohaCare Medicare	$271.50
Rate for Payer: Cash Price	$352.95
Rate for Payer: Cash Price	$352.95
Rate for Payer: Devoted Health Medicare	$298.65
Rate for Payer: Hawaii Medical Service Association ABD	$38.07
Rate for Payer: Hawaii Medical Service Association Medicare	$271.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$515.85
Rate for Payer: Health Management Network Commercial	$461.55
Rate for Payer: Humana Medicare	$271.50
Rate for Payer: Kaiser Permanente Commercial	$488.70
Rate for Payer: Kaiser Permanente Medicaid	$276.93
Rate for Payer: Kaiser Permanente Medicare	$271.50
Rate for Payer: MDX Hawaii PPO	$526.71
Rate for Payer: Ohana Health Plan Medicaid	$271.50
Rate for Payer: Ohana Health Plan Medicare	$271.50
Rate for Payer: UnitedHealthcare Medicaid	$38.07
Rate for Payer: UnitedHealthcare Medicare	$271.50
Rate for Payer: University Health Alliance Commercial	$146.61

HHSC US GUIDANCE NEEDLE PLACEMENT

Facility

$559.00

Service Code	HCPCS 76942
Hospital Charge Code	10232152
Hospital Revenue Code	402
Min. Negotiated Rate	$475.15
Max. Negotiated Rate	$542.23
Rate for Payer: Cash Price	$363.35
Rate for Payer: Health Management Network Commercial	$475.15
Rate for Payer: Kaiser Permanente Commercial	$503.10
Rate for Payer: MDX Hawaii PPO	$542.23

HHSC US GUIDANCE NEEDLE PLACEMENT

Facility

$559.00

Service Code	HCPCS 76942
Hospital Charge Code	10232152
Hospital Revenue Code	402
Min. Negotiated Rate	$73.06
Max. Negotiated Rate	$542.23
Rate for Payer: AlohaCare Medicaid	$279.50
Rate for Payer: AlohaCare Medicare	$279.50
Rate for Payer: Cash Price	$363.35
Rate for Payer: Cash Price	$363.35
Rate for Payer: Devoted Health Medicare	$307.45
Rate for Payer: Hawaii Medical Service Association ABD	$73.06
Rate for Payer: Hawaii Medical Service Association Medicare	$279.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.75
Rate for Payer: Hawaii Western Management Group Commercial	$531.05
Rate for Payer: Health Management Network Commercial	$475.15
Rate for Payer: Humana Medicare	$279.50
Rate for Payer: Kaiser Permanente Commercial	$503.10
Rate for Payer: Kaiser Permanente Medicaid	$285.09
Rate for Payer: Kaiser Permanente Medicare	$279.50
Rate for Payer: MDX Hawaii PPO	$542.23
Rate for Payer: Ohana Health Plan Medicaid	$279.50
Rate for Payer: Ohana Health Plan Medicare	$279.50
Rate for Payer: UnitedHealthcare Medicaid	$73.06
Rate for Payer: UnitedHealthcare Medicare	$279.50
Rate for Payer: University Health Alliance Commercial	$361.51

HHSC US Guided FNA Addl

Professional

Both

$119.00

Service Code	HCPCS 10006
Hospital Charge Code	8223492
Hospital Revenue Code	972
Min. Negotiated Rate	$42.46
Max. Negotiated Rate	$101.15
Rate for Payer: AlohaCare Medicaid	$49.69
Rate for Payer: AlohaCare Medicare	$42.46
Rate for Payer: Cash Price	$77.35
Rate for Payer: Cash Price	$77.35
Rate for Payer: Devoted Health Medicare	$46.71
Rate for Payer: Hawaii Medical Service Association ABD	$49.69
Rate for Payer: Hawaii Medical Service Association Commercial	$78.48
Rate for Payer: Hawaii Medical Service Association Medicare	$42.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49.69
Rate for Payer: Hawaii Western Management Group Commercial	$63.44
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$50.95
Rate for Payer: Kaiser Permanente Medicaid	$50.95
Rate for Payer: Kaiser Permanente Medicare	$50.95
Rate for Payer: Ohana Health Plan Medicaid	$49.69
Rate for Payer: Ohana Health Plan Medicare	$42.46
Rate for Payer: UnitedHealthcare Medicaid	$49.69
Rate for Payer: UnitedHealthcare Medicare	$42.46
Rate for Payer: University Health Alliance Commercial	$53.59

HHSC US Guided FNA Addl

Facility

$1,331.00

Service Code	HCPCS 10006
Hospital Charge Code	8223492
Hospital Revenue Code	361
Min. Negotiated Rate	$1,131.35
Max. Negotiated Rate	$1,291.07
Rate for Payer: Cash Price	$865.15
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Kaiser Permanente Commercial	$1,197.90
Rate for Payer: MDX Hawaii PPO	$1,291.07

HHSC US Guided FNA Addl

Facility

$1,331.00

Service Code	HCPCS 10006
Hospital Charge Code	8223492
Hospital Revenue Code	361
Min. Negotiated Rate	$49.69
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$665.50
Rate for Payer: AlohaCare Medicare	$665.50
Rate for Payer: Cash Price	$865.15
Rate for Payer: Cash Price	$865.15
Rate for Payer: Cash Price	$865.15
Rate for Payer: Devoted Health Medicare	$732.05
Rate for Payer: Hawaii Medical Service Association Medicare	$665.50
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Humana Medicare	$665.50
Rate for Payer: Kaiser Permanente Commercial	$1,197.90
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$665.50
Rate for Payer: MDX Hawaii PPO	$1,291.07
Rate for Payer: Ohana Health Plan Medicaid	$665.50
Rate for Payer: Ohana Health Plan Medicare	$665.50
Rate for Payer: UnitedHealthcare Medicaid	$49.69
Rate for Payer: UnitedHealthcare Medicare	$665.50
Rate for Payer: University Health Alliance Commercial	$745.36

HHSC US OB <14 Wks Ea Addl Fetus

Facility

$269.00

Service Code	HCPCS 76802
Hospital Charge Code	8223510
Hospital Revenue Code	402
Min. Negotiated Rate	$28.71
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	$28.71
Rate for Payer: Hawaii Medical Service Association Medicare	$134.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$34.28
Rate for Payer: Hawaii Western Management Group Commercial	$255.55
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	$28.71
Rate for Payer: UnitedHealthcare Medicare	$134.50
Rate for Payer: University Health Alliance Commercial	$152.61

HHSC US OB <14 Wks Ea Addl Fetus

Facility

$269.00

Service Code	HCPCS 76802
Hospital Charge Code	8223510
Hospital Revenue Code	402
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

HHSC US OB Comp >14 Wk Addl Fetus

Facility

$555.00

Service Code	HCPCS 76810
Hospital Charge Code	8223512
Hospital Revenue Code	402
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$360.75
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: MDX Hawaii PPO	$538.35

HHSC US OB Comp >14 Wk Addl Fetus

Facility

$555.00

Service Code	HCPCS 76810
Hospital Charge Code	8223512
Hospital Revenue Code	402
Min. Negotiated Rate	$48.52
Max. Negotiated Rate	$538.35
Rate for Payer: AlohaCare Medicaid	$277.50
Rate for Payer: AlohaCare Medicare	$277.50
Rate for Payer: Cash Price	$360.75
Rate for Payer: Cash Price	$360.75
Rate for Payer: Devoted Health Medicare	$305.25
Rate for Payer: Hawaii Medical Service Association ABD	$48.52
Rate for Payer: Hawaii Medical Service Association Medicare	$277.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$64.55
Rate for Payer: Hawaii Western Management Group Commercial	$527.25
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Humana Medicare	$277.50
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: Kaiser Permanente Medicare	$277.50
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: Ohana Health Plan Medicaid	$277.50
Rate for Payer: Ohana Health Plan Medicare	$277.50
Rate for Payer: UnitedHealthcare Medicaid	$48.52
Rate for Payer: UnitedHealthcare Medicare	$277.50
Rate for Payer: University Health Alliance Commercial	$195.73

HHSC US OB Transvaginal

Facility

$758.00

Service Code	HCPCS 76817
Hospital Charge Code	8372120
Hospital Revenue Code	402
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

HHSC US OB Transvaginal

Facility

$758.00

Service Code	HCPCS 76817
Hospital Charge Code	8372120
Hospital Revenue Code	402
Min. Negotiated Rate	$46.06
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$46.06
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$53.86
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$46.06
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$193.75

HHSC US Perq Device Breast Ea Addl

Facility

$604.00

Service Code	HCPCS 19286
Hospital Charge Code	8223508
Hospital Revenue Code	361
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$392.60
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: MDX Hawaii PPO	$585.88

HHSC US Perq Device Breast Ea Addl

Facility

$604.00

Service Code	HCPCS 19286
Hospital Charge Code	8223508
Hospital Revenue Code	361
Min. Negotiated Rate	$41.45
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$302.00
Rate for Payer: AlohaCare Medicare	$302.00
Rate for Payer: Cash Price	$392.60
Rate for Payer: Cash Price	$392.60
Rate for Payer: Cash Price	$392.60
Rate for Payer: Devoted Health Medicare	$332.20
Rate for Payer: Hawaii Medical Service Association Medicare	$302.00
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Humana Medicare	$302.00
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$302.00
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: Ohana Health Plan Medicaid	$302.00
Rate for Payer: Ohana Health Plan Medicare	$302.00
Rate for Payer: UnitedHealthcare Medicaid	$41.45
Rate for Payer: UnitedHealthcare Medicare	$302.00
Rate for Payer: University Health Alliance Commercial	$338.24

HHSC US Vac Assisted Biopsy Probe

Facility

$928.00

Service Code	HCPCS A4215
Hospital Charge Code	8223476
Hospital Revenue Code	272
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$900.16
Rate for Payer: AlohaCare Medicaid	$464.00
Rate for Payer: AlohaCare Medicare	$464.00
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cash Price	$603.20
Rate for Payer: Devoted Health Medicare	$510.40
Rate for Payer: Hawaii Medical Service Association Medicare	$464.00
Rate for Payer: Hawaii Western Management Group Commercial	$881.60
Rate for Payer: Health Management Network Commercial	$788.80
Rate for Payer: Humana Medicare	$464.00
Rate for Payer: Kaiser Permanente Commercial	$835.20
Rate for Payer: Kaiser Permanente Medicaid	$473.28
Rate for Payer: Kaiser Permanente Medicare	$464.00
Rate for Payer: MDX Hawaii PPO	$900.16
Rate for Payer: Ohana Health Plan Medicaid	$464.00
Rate for Payer: Ohana Health Plan Medicare	$464.00
Rate for Payer: UnitedHealthcare Medicaid	$0.10
Rate for Payer: UnitedHealthcare Medicare	$464.00
Rate for Payer: University Health Alliance Commercial	$676.42

HHSC US Vac Assisted Biopsy Probe

Facility

$928.00

Service Code	HCPCS A4215
Hospital Charge Code	8223476
Hospital Revenue Code	272
Min. Negotiated Rate	$788.80
Max. Negotiated Rate	$900.16
Rate for Payer: Cash Price	$603.20
Rate for Payer: Health Management Network Commercial	$788.80
Rate for Payer: Kaiser Permanente Commercial	$835.20
Rate for Payer: MDX Hawaii PPO	$900.16

HHSC Vac Assisted Biopsy Probe

Facility

$928.00

Service Code	HCPCS A4215
Hospital Charge Code	8223472
Hospital Revenue Code	272
Min. Negotiated Rate	$788.80
Max. Negotiated Rate	$900.16
Rate for Payer: Cash Price	$603.20
Rate for Payer: Health Management Network Commercial	$788.80
Rate for Payer: Kaiser Permanente Commercial	$835.20
Rate for Payer: MDX Hawaii PPO	$900.16

HHSC Vac Assisted Biopsy Probe

Facility

$928.00

Service Code	HCPCS A4215
Hospital Charge Code	8223472
Hospital Revenue Code	272
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$900.16
Rate for Payer: AlohaCare Medicaid	$464.00
Rate for Payer: AlohaCare Medicare	$464.00
Rate for Payer: Cash Price	$603.20
Rate for Payer: Cash Price	$603.20
Rate for Payer: Devoted Health Medicare	$510.40
Rate for Payer: Hawaii Medical Service Association Medicare	$464.00
Rate for Payer: Hawaii Western Management Group Commercial	$881.60
Rate for Payer: Health Management Network Commercial	$788.80
Rate for Payer: Humana Medicare	$464.00
Rate for Payer: Kaiser Permanente Commercial	$835.20
Rate for Payer: Kaiser Permanente Medicaid	$473.28
Rate for Payer: Kaiser Permanente Medicare	$464.00
Rate for Payer: MDX Hawaii PPO	$900.16
Rate for Payer: Ohana Health Plan Medicaid	$464.00
Rate for Payer: Ohana Health Plan Medicare	$464.00
Rate for Payer: UnitedHealthcare Medicaid	$0.10
Rate for Payer: UnitedHealthcare Medicare	$464.00
Rate for Payer: University Health Alliance Commercial	$676.42

HHSC Xrays at Surgery Addon

Facility

$494.00

Service Code	HCPCS 74301
Hospital Charge Code	8223478
Hospital Revenue Code	320
Min. Negotiated Rate	$247.00
Max. Negotiated Rate	$479.18
Rate for Payer: AlohaCare Medicaid	$247.00
Rate for Payer: AlohaCare Medicare	$247.00
Rate for Payer: Cash Price	$321.10
Rate for Payer: Devoted Health Medicare	$271.70
Rate for Payer: Hawaii Medical Service Association Medicare	$247.00
Rate for Payer: Hawaii Western Management Group Commercial	$469.30
Rate for Payer: Health Management Network Commercial	$419.90
Rate for Payer: Humana Medicare	$247.00
Rate for Payer: Kaiser Permanente Commercial	$444.60
Rate for Payer: Kaiser Permanente Medicaid	$251.94
Rate for Payer: Kaiser Permanente Medicare	$247.00
Rate for Payer: MDX Hawaii PPO	$479.18
Rate for Payer: Ohana Health Plan Medicaid	$247.00
Rate for Payer: Ohana Health Plan Medicare	$247.00
Rate for Payer: UnitedHealthcare Medicare	$247.00
Rate for Payer: University Health Alliance Commercial	$276.64

HHSC Xrays at Surgery Addon

Facility

$494.00

Service Code	HCPCS 74301
Hospital Charge Code	8223478
Hospital Revenue Code	320
Min. Negotiated Rate	$419.90
Max. Negotiated Rate	$479.18
Rate for Payer: Cash Price	$321.10
Rate for Payer: Health Management Network Commercial	$419.90
Rate for Payer: Kaiser Permanente Commercial	$444.60
Rate for Payer: MDX Hawaii PPO	$479.18

HHSC XR Guided FNA Addl

Facility

$1,331.00

Service Code	HCPCS 10008
Hospital Charge Code	8223494
Hospital Revenue Code	361
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$665.50
Rate for Payer: AlohaCare Medicare	$665.50
Rate for Payer: Cash Price	$865.15
Rate for Payer: Cash Price	$865.15
Rate for Payer: Cash Price	$865.15
Rate for Payer: Devoted Health Medicare	$732.05
Rate for Payer: Hawaii Medical Service Association Medicare	$665.50
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Humana Medicare	$665.50
Rate for Payer: Kaiser Permanente Commercial	$1,197.90
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$665.50
Rate for Payer: MDX Hawaii PPO	$1,291.07
Rate for Payer: Ohana Health Plan Medicaid	$665.50
Rate for Payer: Ohana Health Plan Medicare	$665.50
Rate for Payer: UnitedHealthcare Medicaid	$49.35
Rate for Payer: UnitedHealthcare Medicare	$665.50
Rate for Payer: University Health Alliance Commercial	$745.36

HHSC XR Guided FNA Addl

Facility

$1,331.00

Service Code	HCPCS 10008
Hospital Charge Code	8223494
Hospital Revenue Code	361
Min. Negotiated Rate	$1,131.35
Max. Negotiated Rate	$1,291.07
Rate for Payer: Cash Price	$865.15
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Kaiser Permanente Commercial	$1,197.90
Rate for Payer: MDX Hawaii PPO	$1,291.07

HHSC XR Inj Ankle Arthro

Facility

$214.00

Service Code	HCPCS 27648
Hospital Charge Code	8224268
Hospital Revenue Code	361
Min. Negotiated Rate	$39.92
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$107.00
Rate for Payer: AlohaCare Medicare	$107.00
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Cash Price	$139.10
Rate for Payer: Devoted Health Medicare	$117.70
Rate for Payer: Hawaii Medical Service Association Medicare	$107.00
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Humana Medicare	$107.00
Rate for Payer: Kaiser Permanente Commercial	$192.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$107.00
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: Ohana Health Plan Medicaid	$107.00
Rate for Payer: Ohana Health Plan Medicare	$107.00
Rate for Payer: UnitedHealthcare Medicaid	$39.92
Rate for Payer: UnitedHealthcare Medicare	$107.00
Rate for Payer: University Health Alliance Commercial	$119.84

Know your out-of-pocket cost for care.

All Charges