Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

RSV by NAAT FSI

Facility

$591.00

Service Code	HCPCS 87634
Hospital Charge Code	9681125
Hospital Revenue Code	306
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association ABD	$58.84
Rate for Payer: Hawaii Medical Service Association Commercial	$87.75
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$96.95
Rate for Payer: Hawaii Western Management Group Commercial	$70.20
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$52.00
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$160.32

RSV by NAAT FSI

Facility

$591.00

Service Code	HCPCS 87634
Hospital Charge Code	9681125
Hospital Revenue Code	306
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

RSV by PCR FSI

Facility

$591.00

Service Code	HCPCS 87634
Hospital Charge Code	8404547
Hospital Revenue Code	306
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
Rate for Payer: Hawaii Medical Service Association ABD	$58.84
Rate for Payer: Hawaii Medical Service Association Commercial	$87.75
Rate for Payer: Hawaii Medical Service Association Medicare	$295.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$96.95
Rate for Payer: Hawaii Western Management Group Commercial	$70.20
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$52.00
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$160.32

RSV by PCR FSI

Facility

$591.00

Service Code	HCPCS 87634
Hospital Charge Code	8404547
Hospital Revenue Code	306
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

RSV POC

Professional

Both

$92.00

Service Code	HCPCS 87807 QW
Hospital Charge Code	1019809
Hospital Revenue Code	306
Min. Negotiated Rate	$13.10
Max. Negotiated Rate	$78.20
Rate for Payer: AlohaCare Medicaid	$16.58
Rate for Payer: AlohaCare Medicare	$13.10
Rate for Payer: Cash Price	$59.80
Rate for Payer: Cash Price	$59.80
Rate for Payer: Devoted Health Medicare	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$13.10
Rate for Payer: Hawaii Western Management Group Commercial	$16.75
Rate for Payer: Health Management Network Commercial	$78.20
Rate for Payer: Kaiser Permanente Commercial	$15.72
Rate for Payer: Kaiser Permanente Medicaid	$15.72
Rate for Payer: Kaiser Permanente Medicare	$15.72
Rate for Payer: Ohana Health Plan Medicaid	$16.58
Rate for Payer: Ohana Health Plan Medicare	$13.10
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$13.10

RT Aerosol Initial CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8078327
Hospital Revenue Code	410
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

RT Aerosol Initial CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8078327
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

RT Aerosol Subsequent CHARGE

Facility

$428.00

Service Code	HCPCS 94640 76
Hospital Charge Code	8078328
Hospital Revenue Code	410
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

RT Aerosol Subsequent CHARGE

Facility

$428.00

Service Code	HCPCS 94640 76
Hospital Charge Code	8078328
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

RT FLOW VOLUME LOOP CHARGE

Facility

$822.00

Service Code	HCPCS 94375
Hospital Charge Code	8243395
Hospital Revenue Code	460
Min. Negotiated Rate	$15.25
Max. Negotiated Rate	$797.34
Rate for Payer: AlohaCare Medicaid	$411.00
Rate for Payer: AlohaCare Medicare	$411.00
Rate for Payer: Cash Price	$534.30
Rate for Payer: Cash Price	$534.30
Rate for Payer: Devoted Health Medicare	$452.10
Rate for Payer: Hawaii Medical Service Association ABD	$15.25
Rate for Payer: Hawaii Medical Service Association Commercial	$275.75
Rate for Payer: Hawaii Medical Service Association Medicare	$411.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.07
Rate for Payer: Hawaii Western Management Group Commercial	$780.90
Rate for Payer: Health Management Network Commercial	$698.70
Rate for Payer: Humana Medicare	$411.00
Rate for Payer: Kaiser Permanente Commercial	$739.80
Rate for Payer: Kaiser Permanente Medicaid	$419.22
Rate for Payer: Kaiser Permanente Medicare	$411.00
Rate for Payer: MDX Hawaii PPO	$797.34
Rate for Payer: Ohana Health Plan Medicaid	$411.00
Rate for Payer: Ohana Health Plan Medicare	$411.00
Rate for Payer: UnitedHealthcare Medicaid	$15.25
Rate for Payer: UnitedHealthcare Medicare	$411.00
Rate for Payer: University Health Alliance Commercial	$460.32

RT FLOW VOLUME LOOP CHARGE

Facility

$822.00

Service Code	HCPCS 94375
Hospital Charge Code	8243395
Hospital Revenue Code	460
Min. Negotiated Rate	$698.70
Max. Negotiated Rate	$797.34
Rate for Payer: Cash Price	$534.30
Rate for Payer: Health Management Network Commercial	$698.70
Rate for Payer: Kaiser Permanente Commercial	$739.80
Rate for Payer: MDX Hawaii PPO	$797.34

RT Meter Dose Inhaler Initial CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8078351
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

RT Meter Dose Inhaler Initial CHARGE

Facility

$428.00

Service Code	HCPCS 94640
Hospital Charge Code	8078351
Hospital Revenue Code	410
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

RT Meter Dose Inhaler Instruction CHARGE

Facility

$262.00

Service Code	HCPCS 94664
Hospital Charge Code	8078353
Hospital Revenue Code	410
Min. Negotiated Rate	$222.70
Max. Negotiated Rate	$254.14
Rate for Payer: Cash Price	$170.30
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: MDX Hawaii PPO	$254.14

RT Meter Dose Inhaler Instruction CHARGE

Facility

$262.00

Service Code	HCPCS 94664
Hospital Charge Code	8078353
Hospital Revenue Code	410
Min. Negotiated Rate	$14.35
Max. Negotiated Rate	$279.65
Rate for Payer: AlohaCare Medicaid	$131.00
Rate for Payer: AlohaCare Medicare	$131.00
Rate for Payer: Cash Price	$170.30
Rate for Payer: Cash Price	$170.30
Rate for Payer: Devoted Health Medicare	$144.10
Rate for Payer: Hawaii Medical Service Association Commercial	$279.65
Rate for Payer: Hawaii Medical Service Association Medicare	$131.00
Rate for Payer: Hawaii Western Management Group Commercial	$248.90
Rate for Payer: Health Management Network Commercial	$222.70
Rate for Payer: Humana Medicare	$131.00
Rate for Payer: Kaiser Permanente Commercial	$235.80
Rate for Payer: Kaiser Permanente Medicaid	$133.62
Rate for Payer: Kaiser Permanente Medicare	$131.00
Rate for Payer: MDX Hawaii PPO	$254.14
Rate for Payer: Ohana Health Plan Medicaid	$131.00
Rate for Payer: Ohana Health Plan Medicare	$131.00
Rate for Payer: UnitedHealthcare Medicaid	$14.35
Rate for Payer: UnitedHealthcare Medicare	$131.00
Rate for Payer: University Health Alliance Commercial	$146.72

RT Meter Dose Inhaler Subsequent CHARGE

Facility

$428.00

Service Code	HCPCS 94640 76
Hospital Charge Code	8078352
Hospital Revenue Code	410
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

RT Meter Dose Inhaler Subsequent CHARGE

Facility

$428.00

Service Code	HCPCS 94640 76
Hospital Charge Code	8078352
Hospital Revenue Code	410
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$13.32
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$239.68

Rubella AB, Total (Prenatal Rubella Screen) FSI

Facility

$207.00

Service Code	HCPCS 86762
Hospital Charge Code	8228917
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
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	$103.50
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	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicaid	$19.89
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$37.20

Rubella AB, Total (Prenatal Rubella Screen) FSI

Facility

$207.00

Service Code	HCPCS 86762
Hospital Charge Code	8228917
Hospital Revenue Code	302
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

Rubella, IgG (Not for Prenatal) FSI

Facility

$207.00

Service Code	HCPCS 86762
Hospital Charge Code	8118039
Hospital Revenue Code	302
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$134.55
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: MDX Hawaii PPO	$200.79

Rubella, IgG (Not for Prenatal) FSI

Facility

$207.00

Service Code	HCPCS 86762
Hospital Charge Code	8118039
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$200.79
Rate for Payer: AlohaCare Medicaid	$103.50
Rate for Payer: AlohaCare Medicare	$103.50
Rate for Payer: Cash Price	$134.55
Rate for Payer: Cash Price	$134.55
Rate for Payer: Devoted Health Medicare	$113.85
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	$103.50
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	$175.95
Rate for Payer: Humana Medicare	$103.50
Rate for Payer: Kaiser Permanente Commercial	$186.30
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: Kaiser Permanente Medicare	$103.50
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: Ohana Health Plan Medicaid	$103.50
Rate for Payer: Ohana Health Plan Medicare	$103.50
Rate for Payer: UnitedHealthcare Medicaid	$19.89
Rate for Payer: UnitedHealthcare Medicare	$103.50
Rate for Payer: University Health Alliance Commercial	$37.20

Rubeola, IgG FSI

Facility

$147.00

Service Code	HCPCS 86765
Hospital Charge Code	8118040
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$33.30

Rubeola, IgG FSI

Facility

$147.00

Service Code	HCPCS 86765
Hospital Charge Code	8118040
Hospital Revenue Code	302
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Rubeola, IgM Ab FSI

Facility

$147.00

Service Code	HCPCS 86765
Hospital Charge Code	8118041
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.81
Rate for Payer: Hawaii Medical Service Association Commercial	$16.10
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.70
Rate for Payer: Hawaii Western Management Group Commercial	$12.88
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$17.81
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$33.30

Rubeola, IgM Ab FSI

Facility

$147.00

Service Code	HCPCS 86765
Hospital Charge Code	8118041
Hospital Revenue Code	302
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Know your out-of-pocket cost for care.

All Charges