Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC MRI, JOINT UPPER EXTREM WO IV CONTRAST

Facility

$1,203.00

Service Code	HCPCS 73221
Hospital Charge Code	6107322107
Hospital Revenue Code	610
Min. Negotiated Rate	$281.87
Max. Negotiated Rate	$1,166.91
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cash Price	$721.80
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$415.68
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$426.65
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$757.89
Rate for Payer: Kaiser Permanente Medicaid	$613.53
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,166.91
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$415.68
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$837.57

HC MRI, JOINT UPPER EXTREM WO IV CONTRAST

Facility

$1,203.00

Service Code	HCPCS 73221
Hospital Charge Code	6107322107
Hospital Revenue Code	610
Min. Negotiated Rate	$1,022.55
Max. Negotiated Rate	$1,166.91
Rate for Payer: Cash Price	$721.80
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: MDX Hawaii PPO	$1,166.91

HC MRI JOINT UPR EXTREM W/DYE - MR ELBOW W IV CONTRAST

Facility

$3,930.00

Service Code	HCPCS 73222
Hospital Charge Code	6147322207
Hospital Revenue Code	614
Min. Negotiated Rate	$3,340.50
Max. Negotiated Rate	$3,812.10
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Health Management Network Commercial	$3,340.50
Rate for Payer: MDX Hawaii PPO	$3,812.10

HC MRI JOINT UPR EXTREM W/DYE - MR ELBOW W IV CONTRAST

Facility

$3,930.00

Service Code	HCPCS 73222
Hospital Charge Code	6147322207
Hospital Revenue Code	614
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$3,812.10
Rate for Payer: AlohaCare Medicaid	$926.08
Rate for Payer: AlohaCare Medicare	$926.08
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Devoted Health Medicare	$1,018.69
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Commercial	$1,157.60
Rate for Payer: Hawaii Medical Service Association Medicare	$926.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$926.08
Rate for Payer: Health Management Network Commercial	$3,340.50
Rate for Payer: Humana Medicare	$926.08
Rate for Payer: Kaiser Permanente Commercial	$2,475.90
Rate for Payer: Kaiser Permanente Medicaid	$2,004.30
Rate for Payer: Kaiser Permanente Medicare	$926.08
Rate for Payer: MDX Hawaii PPO	$3,812.10
Rate for Payer: Ohana Health Plan Medicaid	$1,018.69
Rate for Payer: Ohana Health Plan Medicare	$926.08
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$926.08
Rate for Payer: University Health Alliance Commercial	$973.95

HC MRI JOINT UPR EXTREM W/DYE - MR SHOULDER W IV CONTRAST

Facility

$3,930.00

Service Code	HCPCS 73222
Hospital Charge Code	6147322208
Hospital Revenue Code	614
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$3,812.10
Rate for Payer: AlohaCare Medicaid	$926.08
Rate for Payer: AlohaCare Medicare	$926.08
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Devoted Health Medicare	$1,018.69
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Commercial	$1,157.60
Rate for Payer: Hawaii Medical Service Association Medicare	$926.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$926.08
Rate for Payer: Health Management Network Commercial	$3,340.50
Rate for Payer: Humana Medicare	$926.08
Rate for Payer: Kaiser Permanente Commercial	$2,475.90
Rate for Payer: Kaiser Permanente Medicaid	$2,004.30
Rate for Payer: Kaiser Permanente Medicare	$926.08
Rate for Payer: MDX Hawaii PPO	$3,812.10
Rate for Payer: Ohana Health Plan Medicaid	$1,018.69
Rate for Payer: Ohana Health Plan Medicare	$926.08
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$926.08
Rate for Payer: University Health Alliance Commercial	$973.95

HC MRI JOINT UPR EXTREM W/DYE - MR SHOULDER W IV CONTRAST

Facility

$3,930.00

Service Code	HCPCS 73222
Hospital Charge Code	6147322208
Hospital Revenue Code	614
Min. Negotiated Rate	$3,340.50
Max. Negotiated Rate	$3,812.10
Rate for Payer: Cash Price	$2,358.00
Rate for Payer: Health Management Network Commercial	$3,340.50
Rate for Payer: MDX Hawaii PPO	$3,812.10

HC MRI JOINT UPR EXTR W AND WO IV CONTRAST

Facility

$1,776.00

Service Code	HCPCS 73223
Hospital Charge Code	6107322305
Hospital Revenue Code	610
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI JOINT UPR EXTR W AND WO IV CONTRAST

Facility

$1,776.00

Service Code	HCPCS 73223
Hospital Charge Code	6107322305
Hospital Revenue Code	610
Min. Negotiated Rate	$412.14
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$983.00
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$952.52
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$983.00
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$1,285.53

HC MRI, LOWER EXTREM W/CONTRAST - MR FOOT W IV CONTRAST

Facility

$1,776.00

Service Code	HCPCS 73719
Hospital Charge Code	6147371901
Hospital Revenue Code	614
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI, LOWER EXTREM W/CONTRAST - MR FOOT W IV CONTRAST

Facility

$1,776.00

Service Code	HCPCS 73719
Hospital Charge Code	6147371901
Hospital Revenue Code	614
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$974.25

HC MRI, LOWER EXTREM W/CONTRAST - MR TIBIA FIBULA W IV CONTRAST

Facility

$1,776.00

Service Code	HCPCS 73719
Hospital Charge Code	6147371903
Hospital Revenue Code	614
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI, LOWER EXTREM W/CONTRAST - MR TIBIA FIBULA W IV CONTRAST

Facility

$1,776.00

Service Code	HCPCS 73719
Hospital Charge Code	6147371903
Hospital Revenue Code	614
Min. Negotiated Rate	$382.28
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$382.28
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$475.88
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$382.28
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$974.25

HC MRI, LOWER EXTREM WO IV CONTRAST

Facility

$1,203.00

Service Code	HCPCS 73718
Hospital Charge Code	6107371805
Hospital Revenue Code	610
Min. Negotiated Rate	$281.87
Max. Negotiated Rate	$1,166.91
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cash Price	$721.80
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$318.66
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$396.79
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$757.89
Rate for Payer: Kaiser Permanente Medicaid	$613.53
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,166.91
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$318.66
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$837.87

HC MRI, LOWER EXTREM WO IV CONTRAST

Facility

$1,203.00

Service Code	HCPCS 73718
Hospital Charge Code	6107371805
Hospital Revenue Code	610
Min. Negotiated Rate	$1,022.55
Max. Negotiated Rate	$1,166.91
Rate for Payer: Cash Price	$721.80
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: MDX Hawaii PPO	$1,166.91

HC MRI, LUMBAR SPINE COMBO - MRI LUMBAR SPINE W WO CONTRAST

Facility

$1,776.00

Service Code	HCPCS 72158
Hospital Charge Code	6127215801
Hospital Revenue Code	612
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI, LUMBAR SPINE COMBO - MRI LUMBAR SPINE W WO CONTRAST

Facility

$1,776.00

Service Code	HCPCS 72158
Hospital Charge Code	6127215801
Hospital Revenue Code	612
Min. Negotiated Rate	$412.14
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$819.67
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$883.39
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$819.67
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$1,297.22

HC MRI, LUMBAR SPINE - MRI LUMBAR SPINE WO CONTRAST

Facility

$1,203.00

Service Code	HCPCS 72148
Hospital Charge Code	6127214802
Hospital Revenue Code	612
Min. Negotiated Rate	$281.87
Max. Negotiated Rate	$1,166.91
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cash Price	$721.80
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$439.71
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$461.70
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$757.89
Rate for Payer: Kaiser Permanente Medicaid	$613.53
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,166.91
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$439.71
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$844.93

HC MRI, LUMBAR SPINE - MRI LUMBAR SPINE WO CONTRAST

Facility

$1,203.00

Service Code	HCPCS 72148
Hospital Charge Code	6127214802
Hospital Revenue Code	612
Min. Negotiated Rate	$1,022.55
Max. Negotiated Rate	$1,166.91
Rate for Payer: Cash Price	$721.80
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: MDX Hawaii PPO	$1,166.91

HC MRI LWR EXTREMITY W AND WO IV CONT

Facility

$1,776.00

Service Code	HCPCS 73720
Hospital Charge Code	6107372001
Hospital Revenue Code	610
Min. Negotiated Rate	$412.14
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$645.58
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$880.75
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$645.58
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$1,285.82

HC MRI LWR EXTREMITY W AND WO IV CONT

Facility

$1,776.00

Service Code	HCPCS 73720
Hospital Charge Code	6107372001
Hospital Revenue Code	610
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI, PELVIS, COMBO - MRI PELVIS W WO CONTRAST

Facility

$1,776.00

Service Code	HCPCS 72197
Hospital Charge Code	6147219701
Hospital Revenue Code	614
Min. Negotiated Rate	$412.14
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$709.06
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$882.31
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$709.06
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$1,294.91

HC MRI, PELVIS, COMBO - MRI PELVIS W WO CONTRAST

Facility

$1,776.00

Service Code	HCPCS 72197
Hospital Charge Code	6147219701
Hospital Revenue Code	614
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI PELVIS W/CONTRAST MATERIAL

Facility

$1,776.00

Service Code	HCPCS 72196
Hospital Charge Code	6147219601
Hospital Revenue Code	614
Min. Negotiated Rate	$369.03
Max. Negotiated Rate	$1,722.72
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$369.03
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$476.94
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$1,118.88
Rate for Payer: Kaiser Permanente Medicaid	$905.76
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,722.72
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$369.03
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$983.44

HC MRI PELVIS W/CONTRAST MATERIAL

Facility

$1,776.00

Service Code	HCPCS 72196
Hospital Charge Code	6147219601
Hospital Revenue Code	614
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$1,722.72
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Health Management Network Commercial	$1,509.60
Rate for Payer: MDX Hawaii PPO	$1,722.72

HC MRI, PELVIS, W/O CONTRAST - MRI PELVIS WO CONTRAST

Facility

$1,203.00

Service Code	HCPCS 72195
Hospital Charge Code	6147219501
Hospital Revenue Code	614
Min. Negotiated Rate	$281.87
Max. Negotiated Rate	$1,166.91
Rate for Payer: AlohaCare Medicaid	$281.87
Rate for Payer: AlohaCare Medicare	$281.87
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cash Price	$721.80
Rate for Payer: Devoted Health Medicare	$310.06
Rate for Payer: Hawaii Medical Service Association ABD	$319.74
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$281.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$398.10
Rate for Payer: Hawaii Western Management Group Commercial	$281.87
Rate for Payer: Health Management Network Commercial	$1,022.55
Rate for Payer: Humana Medicare	$281.87
Rate for Payer: Kaiser Permanente Commercial	$757.89
Rate for Payer: Kaiser Permanente Medicaid	$613.53
Rate for Payer: Kaiser Permanente Medicare	$281.87
Rate for Payer: MDX Hawaii PPO	$1,166.91
Rate for Payer: Ohana Health Plan Medicaid	$310.06
Rate for Payer: Ohana Health Plan Medicare	$281.87
Rate for Payer: UnitedHealthcare Medicaid	$319.74
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$846.97

Know your out-of-pocket cost for care.

All Charges