Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

SPINE & PAIN: BOSTON SCIENTIFIC 4 CM SUTURE SLEEVE SET OF 1

Facility

$300.00

Hospital Charge Code	9458970
Hospital Revenue Code	272
Min. Negotiated Rate	$255.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Health Management Network Commercial	$255.00
Rate for Payer: Kaiser Permanente Commercial	$270.00
Rate for Payer: MDX Hawaii PPO	$291.00

SPINE & PAIN: BOSTON SCIENTIFIC ALPHA FREELINK REMOTE CONTROL KIT

Facility

$2,000.00

Hospital Charge Code	9467818
Hospital Revenue Code	272
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,000.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Devoted Health Medicare	$1,100.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,900.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,000.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,000.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,000.00
Rate for Payer: Ohana Health Plan Medicare	$1,000.00
Rate for Payer: UnitedHealthcare Medicare	$1,000.00
Rate for Payer: University Health Alliance Commercial	$1,457.80

SPINE & PAIN: BOSTON SCIENTIFIC ALPHA FREELINK REMOTE CONTROL KIT

Facility

$2,000.00

Hospital Charge Code	9467818
Hospital Revenue Code	272
Min. Negotiated Rate	$1,700.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00

SPINE & PAIN: BOSTON SCIENTIFIC-ALPHA FREELINK REMOTE CONTROL KIT-BLE

Facility

$2,400.00

Service Code	HCPCS C1787
Hospital Charge Code	9558886
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SPINE & PAIN: BOSTON SCIENTIFIC-ALPHA FREELINK REMOTE CONTROL KIT-BLE

Facility

$2,400.00

Service Code	HCPCS C1787
Hospital Charge Code	9558886
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,200.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Devoted Health Medicare	$1,320.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,200.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,200.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,200.00
Rate for Payer: Ohana Health Plan Medicare	$1,200.00
Rate for Payer: UnitedHealthcare Medicare	$1,200.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN MRI SURGICAL LEAD 50 CM

Facility

$21,320.00

Service Code	HCPCS C1778
Hospital Charge Code	9456768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,939.20
Max. Negotiated Rate	$20,680.40
Rate for Payer: Cash Price	$13,858.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,924.00
Rate for Payer: Health Management Network Commercial	$18,122.00
Rate for Payer: Kaiser Permanente Commercial	$19,188.00
Rate for Payer: MDX Hawaii PPO	$20,680.40
Rate for Payer: University Health Alliance Commercial	$11,939.20

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN MRI SURGICAL LEAD 50 CM

Facility

$21,320.00

Service Code	HCPCS C1778
Hospital Charge Code	9456768
Hospital Revenue Code	278
Min. Negotiated Rate	$10,660.00
Max. Negotiated Rate	$20,680.40
Rate for Payer: AlohaCare Medicaid	$10,660.00
Rate for Payer: AlohaCare Medicare	$10,660.00
Rate for Payer: Cash Price	$13,858.00
Rate for Payer: Devoted Health Medicare	$11,726.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10,660.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,924.00
Rate for Payer: Health Management Network Commercial	$18,122.00
Rate for Payer: Humana Medicare	$10,660.00
Rate for Payer: Kaiser Permanente Commercial	$19,188.00
Rate for Payer: Kaiser Permanente Medicaid	$10,873.20
Rate for Payer: Kaiser Permanente Medicare	$10,660.00
Rate for Payer: MDX Hawaii PPO	$20,680.40
Rate for Payer: Ohana Health Plan Medicaid	$10,660.00
Rate for Payer: Ohana Health Plan Medicare	$10,660.00
Rate for Payer: UnitedHealthcare Medicare	$10,660.00
Rate for Payer: University Health Alliance Commercial	$11,939.20

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN MRI SURGICAL LEAD 70 CM

Facility

$21,320.00

Service Code	HCPCS C1778
Hospital Charge Code	9456769
Hospital Revenue Code	278
Min. Negotiated Rate	$10,660.00
Max. Negotiated Rate	$20,680.40
Rate for Payer: AlohaCare Medicaid	$10,660.00
Rate for Payer: AlohaCare Medicare	$10,660.00
Rate for Payer: Cash Price	$13,858.00
Rate for Payer: Devoted Health Medicare	$11,726.00
Rate for Payer: Hawaii Medical Service Association Medicare	$10,660.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,924.00
Rate for Payer: Health Management Network Commercial	$18,122.00
Rate for Payer: Humana Medicare	$10,660.00
Rate for Payer: Kaiser Permanente Commercial	$19,188.00
Rate for Payer: Kaiser Permanente Medicaid	$10,873.20
Rate for Payer: Kaiser Permanente Medicare	$10,660.00
Rate for Payer: MDX Hawaii PPO	$20,680.40
Rate for Payer: Ohana Health Plan Medicaid	$10,660.00
Rate for Payer: Ohana Health Plan Medicare	$10,660.00
Rate for Payer: UnitedHealthcare Medicare	$10,660.00
Rate for Payer: University Health Alliance Commercial	$11,939.20

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN MRI SURGICAL LEAD 70 CM

Facility

$21,320.00

Service Code	HCPCS C1778
Hospital Charge Code	9456769
Hospital Revenue Code	278
Min. Negotiated Rate	$11,939.20
Max. Negotiated Rate	$20,680.40
Rate for Payer: Cash Price	$13,858.00
Rate for Payer: Hawaii Western Management Group Commercial	$14,924.00
Rate for Payer: Health Management Network Commercial	$18,122.00
Rate for Payer: Kaiser Permanente Commercial	$19,188.00
Rate for Payer: MDX Hawaii PPO	$20,680.40
Rate for Payer: University Health Alliance Commercial	$11,939.20

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN SURGICAL LEAD WITH PLATNALOCK TECHNOLOGY 50 CM

Facility

$16,400.00

Service Code	HCPCS C1778
Hospital Charge Code	9456766
Hospital Revenue Code	278
Min. Negotiated Rate	$8,200.00
Max. Negotiated Rate	$15,908.00
Rate for Payer: AlohaCare Medicaid	$8,200.00
Rate for Payer: AlohaCare Medicare	$8,200.00
Rate for Payer: Cash Price	$10,660.00
Rate for Payer: Devoted Health Medicare	$9,020.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,480.00
Rate for Payer: Health Management Network Commercial	$13,940.00
Rate for Payer: Humana Medicare	$8,200.00
Rate for Payer: Kaiser Permanente Commercial	$14,760.00
Rate for Payer: Kaiser Permanente Medicaid	$8,364.00
Rate for Payer: Kaiser Permanente Medicare	$8,200.00
Rate for Payer: MDX Hawaii PPO	$15,908.00
Rate for Payer: Ohana Health Plan Medicaid	$8,200.00
Rate for Payer: Ohana Health Plan Medicare	$8,200.00
Rate for Payer: UnitedHealthcare Medicare	$8,200.00
Rate for Payer: University Health Alliance Commercial	$9,184.00

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN SURGICAL LEAD WITH PLATNALOCK TECHNOLOGY 50 CM

Facility

$16,400.00

Service Code	HCPCS C1778
Hospital Charge Code	9456766
Hospital Revenue Code	278
Min. Negotiated Rate	$9,184.00
Max. Negotiated Rate	$15,908.00
Rate for Payer: Cash Price	$10,660.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,480.00
Rate for Payer: Health Management Network Commercial	$13,940.00
Rate for Payer: Kaiser Permanente Commercial	$14,760.00
Rate for Payer: MDX Hawaii PPO	$15,908.00
Rate for Payer: University Health Alliance Commercial	$9,184.00

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN SURGICAL LEAD WITH PLATNALOCK TECHNOLOGY 70 CM

Facility

$16,400.00

Service Code	HCPCS C1778
Hospital Charge Code	9456767
Hospital Revenue Code	278
Min. Negotiated Rate	$8,200.00
Max. Negotiated Rate	$15,908.00
Rate for Payer: AlohaCare Medicaid	$8,200.00
Rate for Payer: AlohaCare Medicare	$8,200.00
Rate for Payer: Cash Price	$10,660.00
Rate for Payer: Devoted Health Medicare	$9,020.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,480.00
Rate for Payer: Health Management Network Commercial	$13,940.00
Rate for Payer: Humana Medicare	$8,200.00
Rate for Payer: Kaiser Permanente Commercial	$14,760.00
Rate for Payer: Kaiser Permanente Medicaid	$8,364.00
Rate for Payer: Kaiser Permanente Medicare	$8,200.00
Rate for Payer: MDX Hawaii PPO	$15,908.00
Rate for Payer: Ohana Health Plan Medicaid	$8,200.00
Rate for Payer: Ohana Health Plan Medicare	$8,200.00
Rate for Payer: UnitedHealthcare Medicare	$8,200.00
Rate for Payer: University Health Alliance Commercial	$9,184.00

SPINE & PAIN: BOSTON SCIENTIFIC ARTISAN SURGICAL LEAD WITH PLATNALOCK TECHNOLOGY 70 CM

Facility

$16,400.00

Service Code	HCPCS C1778
Hospital Charge Code	9456767
Hospital Revenue Code	278
Min. Negotiated Rate	$9,184.00
Max. Negotiated Rate	$15,908.00
Rate for Payer: Cash Price	$10,660.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,480.00
Rate for Payer: Health Management Network Commercial	$13,940.00
Rate for Payer: Kaiser Permanente Commercial	$14,760.00
Rate for Payer: MDX Hawaii PPO	$15,908.00
Rate for Payer: University Health Alliance Commercial	$9,184.00

SPINE & PAIN: BOSTON SCIENTIFIC AVISTA MRI SAFE LEAD KIT 56CM

Facility

$9,240.00

Service Code	HCPCS C1778
Hospital Charge Code	9452705
Hospital Revenue Code	278
Min. Negotiated Rate	$5,174.40
Max. Negotiated Rate	$8,962.80
Rate for Payer: Cash Price	$6,006.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,468.00
Rate for Payer: Health Management Network Commercial	$7,854.00
Rate for Payer: Kaiser Permanente Commercial	$8,316.00
Rate for Payer: MDX Hawaii PPO	$8,962.80
Rate for Payer: University Health Alliance Commercial	$5,174.40

SPINE & PAIN: BOSTON SCIENTIFIC AVISTA MRI SAFE LEAD KIT 56CM

Facility

$9,240.00

Service Code	HCPCS C1778
Hospital Charge Code	9452705
Hospital Revenue Code	278
Min. Negotiated Rate	$4,620.00
Max. Negotiated Rate	$8,962.80
Rate for Payer: AlohaCare Medicaid	$4,620.00
Rate for Payer: AlohaCare Medicare	$4,620.00
Rate for Payer: Cash Price	$6,006.00
Rate for Payer: Devoted Health Medicare	$5,082.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,620.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,468.00
Rate for Payer: Health Management Network Commercial	$7,854.00
Rate for Payer: Humana Medicare	$4,620.00
Rate for Payer: Kaiser Permanente Commercial	$8,316.00
Rate for Payer: Kaiser Permanente Medicaid	$4,712.40
Rate for Payer: Kaiser Permanente Medicare	$4,620.00
Rate for Payer: MDX Hawaii PPO	$8,962.80
Rate for Payer: Ohana Health Plan Medicaid	$4,620.00
Rate for Payer: Ohana Health Plan Medicare	$4,620.00
Rate for Payer: UnitedHealthcare Medicare	$4,620.00
Rate for Payer: University Health Alliance Commercial	$5,174.40

SPINE & PAIN: BOSTON SCIENTIFIC AVITA STYLEY KIT WITH STEERING CAP 56CM

Facility

$694.00

Hospital Charge Code	9452311
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC AVITA STYLEY KIT WITH STEERING CAP 56CM

Facility

$694.00

Hospital Charge Code	9452311
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC AVITA STYLEY KIT WITH STEERING CAP 74CM

Facility

$694.00

Hospital Charge Code	9452312
Hospital Revenue Code	272
Min. Negotiated Rate	$589.90
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$451.10
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: MDX Hawaii PPO	$673.18

SPINE & PAIN: BOSTON SCIENTIFIC AVITA STYLEY KIT WITH STEERING CAP 74CM

Facility

$694.00

Hospital Charge Code	9452312
Hospital Revenue Code	272
Min. Negotiated Rate	$347.00
Max. Negotiated Rate	$673.18
Rate for Payer: AlohaCare Medicaid	$347.00
Rate for Payer: AlohaCare Medicare	$347.00
Rate for Payer: Cash Price	$451.10
Rate for Payer: Devoted Health Medicare	$381.70
Rate for Payer: Hawaii Medical Service Association Medicare	$347.00
Rate for Payer: Hawaii Western Management Group Commercial	$659.30
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Humana Medicare	$347.00
Rate for Payer: Kaiser Permanente Commercial	$624.60
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: Kaiser Permanente Medicare	$347.00
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: Ohana Health Plan Medicaid	$347.00
Rate for Payer: Ohana Health Plan Medicare	$347.00
Rate for Payer: UnitedHealthcare Medicare	$347.00
Rate for Payer: University Health Alliance Commercial	$505.86

SPINE & PAIN: BOSTON SCIENTIFIC CHARGING KIT 2.0

Facility

$2,000.00

Service Code	HCPCS C1820
Hospital Charge Code	8882335
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: AlohaCare Medicaid	$1,000.00
Rate for Payer: AlohaCare Medicare	$1,000.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Devoted Health Medicare	$1,100.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Humana Medicare	$1,000.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: Kaiser Permanente Medicare	$1,000.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: Ohana Health Plan Medicaid	$1,000.00
Rate for Payer: Ohana Health Plan Medicare	$1,000.00
Rate for Payer: UnitedHealthcare Medicare	$1,000.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

SPINE & PAIN: BOSTON SCIENTIFIC CHARGING KIT 2.0

Facility

$2,000.00

Service Code	HCPCS C1820
Hospital Charge Code	8882335
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,800.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

SPINE & PAIN: BOSTON SCIENTIFIC CLICK ANCHOR (SET OF 2)

Facility

$1,173.00

Hospital Charge Code	8882332
Hospital Revenue Code	272
Min. Negotiated Rate	$997.05
Max. Negotiated Rate	$1,137.81
Rate for Payer: Cash Price	$762.45
Rate for Payer: Health Management Network Commercial	$997.05
Rate for Payer: Kaiser Permanente Commercial	$1,055.70
Rate for Payer: MDX Hawaii PPO	$1,137.81

SPINE & PAIN: BOSTON SCIENTIFIC CLICK ANCHOR (SET OF 2)

Facility

$1,173.00

Hospital Charge Code	8882332
Hospital Revenue Code	272
Min. Negotiated Rate	$586.50
Max. Negotiated Rate	$1,137.81
Rate for Payer: AlohaCare Medicaid	$586.50
Rate for Payer: AlohaCare Medicare	$586.50
Rate for Payer: Cash Price	$762.45
Rate for Payer: Devoted Health Medicare	$645.15
Rate for Payer: Hawaii Medical Service Association Medicare	$586.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,114.35
Rate for Payer: Health Management Network Commercial	$997.05
Rate for Payer: Humana Medicare	$586.50
Rate for Payer: Kaiser Permanente Commercial	$1,055.70
Rate for Payer: Kaiser Permanente Medicaid	$598.23
Rate for Payer: Kaiser Permanente Medicare	$586.50
Rate for Payer: MDX Hawaii PPO	$1,137.81
Rate for Payer: Ohana Health Plan Medicaid	$586.50
Rate for Payer: Ohana Health Plan Medicare	$586.50
Rate for Payer: UnitedHealthcare Medicare	$586.50
Rate for Payer: University Health Alliance Commercial	$855.00

SPINE & PAIN BOSTON SCIENTIFIC CLIK X ANCHOR (SET OF 2)

Facility

$1,173.00

Service Code	HCPCS C1713
Hospital Charge Code	8813156
Hospital Revenue Code	278
Min. Negotiated Rate	$586.50
Max. Negotiated Rate	$1,137.81
Rate for Payer: AlohaCare Medicaid	$586.50
Rate for Payer: AlohaCare Medicare	$586.50
Rate for Payer: Cash Price	$762.45
Rate for Payer: Devoted Health Medicare	$645.15
Rate for Payer: Hawaii Medical Service Association Medicare	$586.50
Rate for Payer: Hawaii Western Management Group Commercial	$821.10
Rate for Payer: Health Management Network Commercial	$997.05
Rate for Payer: Humana Medicare	$586.50
Rate for Payer: Kaiser Permanente Commercial	$1,055.70
Rate for Payer: Kaiser Permanente Medicaid	$598.23
Rate for Payer: Kaiser Permanente Medicare	$586.50
Rate for Payer: MDX Hawaii PPO	$1,137.81
Rate for Payer: Ohana Health Plan Medicaid	$586.50
Rate for Payer: Ohana Health Plan Medicare	$586.50
Rate for Payer: UnitedHealthcare Medicare	$586.50
Rate for Payer: University Health Alliance Commercial	$656.88

SPINE & PAIN BOSTON SCIENTIFIC CLIK X ANCHOR (SET OF 2)

Facility

$1,173.00

Service Code	HCPCS C1713
Hospital Charge Code	8813156
Hospital Revenue Code	278
Min. Negotiated Rate	$656.88
Max. Negotiated Rate	$1,137.81
Rate for Payer: Cash Price	$762.45
Rate for Payer: Hawaii Western Management Group Commercial	$821.10
Rate for Payer: Health Management Network Commercial	$997.05
Rate for Payer: Kaiser Permanente Commercial	$1,055.70
Rate for Payer: MDX Hawaii PPO	$1,137.81
Rate for Payer: University Health Alliance Commercial	$656.88

Know your out-of-pocket cost for care.

All Charges