Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HC X-RAY HEEL - XR CALCANEUS 2 VIEWS

Facility

$438.00

Service Code	HCPCS 73650
Hospital Charge Code	3207365001
Hospital Revenue Code	320
Min. Negotiated Rate	$17.03
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$17.03
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$17.03
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$53.87

HC X-RAY HEEL - XR CALCANEUS 2 VIEWS

Facility

$438.00

Service Code	HCPCS 73650
Hospital Charge Code	3207365001
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY HUMERUS - XR HUMERUS

Facility

$438.00

Service Code	HCPCS 73060
Hospital Charge Code	3207306002
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$61.20

HC X-RAY HUMERUS - XR HUMERUS

Facility

$438.00

Service Code	HCPCS 73060
Hospital Charge Code	3207306002
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY HYSTEROSALPINGOGRAM - XR HYSTEROSALPINGOGRAM

Facility

$1,203.00

Service Code	HCPCS 74740
Hospital Charge Code	3207474001
Hospital Revenue Code	320
Min. Negotiated Rate	$42.98
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	$42.98
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	$46.81
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	$42.98
Rate for Payer: UnitedHealthcare Medicare	$281.87
Rate for Payer: University Health Alliance Commercial	$156.07

HC X-RAY HYSTEROSALPINGOGRAM - XR HYSTEROSALPINGOGRAM

Facility

$1,203.00

Service Code	HCPCS 74740
Hospital Charge Code	3207474001
Hospital Revenue Code	320
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 X-RAY IV PYELOGRAM (IVP) - FL INTRAVENOUS PYELOGRAM

Facility

$885.00

Service Code	HCPCS 74400
Hospital Charge Code	3207440002
Hospital Revenue Code	320
Min. Negotiated Rate	$752.25
Max. Negotiated Rate	$858.45
Rate for Payer: Cash Price	$531.00
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: MDX Hawaii PPO	$858.45

HC X-RAY IV PYELOGRAM (IVP) - FL INTRAVENOUS PYELOGRAM

Facility

$885.00

Service Code	HCPCS 74400
Hospital Charge Code	3207440002
Hospital Revenue Code	320
Min. Negotiated Rate	$55.90
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$752.25
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$557.55
Rate for Payer: Kaiser Permanente Medicaid	$451.35
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$858.45
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$55.90
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$214.84

HC X-RAY JAW <4 VW - XR MANDIBLE < 4 VIEWS

Facility

$438.00

Service Code	HCPCS 70100
Hospital Charge Code	3207010001
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY JAW <4 VW - XR MANDIBLE < 4 VIEWS

Facility

$438.00

Service Code	HCPCS 70100
Hospital Charge Code	3207010001
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.57
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$61.70

HC X-RAY JAW 4+ VW - XR MANDIBLE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 70110
Hospital Charge Code	3207011001
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$78.16

HC X-RAY JAW 4+ VW - XR MANDIBLE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 70110
Hospital Charge Code	3207011001
Hospital Revenue Code	320
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC X-RAY KNEE 1 OR 2 VIEW - XR KNEE 1-2 VIEWS

Facility

$438.00

Service Code	HCPCS 73560
Hospital Charge Code	3207356001
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$58.59

HC X-RAY KNEE 1 OR 2 VIEW - XR KNEE 1-2 VIEWS

Facility

$438.00

Service Code	HCPCS 73560
Hospital Charge Code	3207356001
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY KNEE 3 VIEW - XR KNEE 3 VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73562
Hospital Charge Code	3207356203
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$68.32

HC X-RAY KNEE 3 VIEW - XR KNEE 3 VIEWS BILATERAL

Facility

$438.00

Service Code	HCPCS 73562
Hospital Charge Code	3207356203
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY KNEE 4+ VIEW - XR KNEE 4+ VIEWS BILATERAL

Facility

$529.00

Service Code	HCPCS 73564
Hospital Charge Code	3207356403
Hospital Revenue Code	320
Min. Negotiated Rate	$22.13
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$22.13
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.24
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$22.13
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$77.64

HC X-RAY KNEE 4+ VIEW - XR KNEE 4+ VIEWS BILATERAL

Facility

$529.00

Service Code	HCPCS 73564
Hospital Charge Code	3207356403
Hospital Revenue Code	320
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC X-RAY KNEE BILAT STANDING - XR KNEES ANTEROPOSTERIOR STANDING BILAT

Facility

$438.00

Service Code	HCPCS 73565
Hospital Charge Code	3207356501
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$60.18

HC X-RAY KNEE BILAT STANDING - XR KNEES ANTEROPOSTERIOR STANDING BILAT

Facility

$438.00

Service Code	HCPCS 73565
Hospital Charge Code	3207356501
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY LEG, INFANT - XR LOWER EXTREMITY 2+ VIEWS INFANT

Facility

$438.00

Service Code	HCPCS 73592
Hospital Charge Code	3207359201
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$424.86
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$275.94
Rate for Payer: Kaiser Permanente Medicaid	$223.38
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$424.86
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$56.28

HC X-RAY LEG, INFANT - XR LOWER EXTREMITY 2+ VIEWS INFANT

Facility

$438.00

Service Code	HCPCS 73592
Hospital Charge Code	3207359201
Hospital Revenue Code	320
Min. Negotiated Rate	$372.30
Max. Negotiated Rate	$424.86
Rate for Payer: Cash Price	$262.80
Rate for Payer: Health Management Network Commercial	$372.30
Rate for Payer: MDX Hawaii PPO	$424.86

HC X-RAY LUMBAR SPINE 2/3 VW - XR LUMBAR SPINE 2-3 VIEWS

Facility

$529.00

Service Code	HCPCS 72100
Hospital Charge Code	3207210001
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$21.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$21.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$77.64

HC X-RAY LUMBAR SPINE 2/3 VW - XR LUMBAR SPINE 2-3 VIEWS

Facility

$529.00

Service Code	HCPCS 72100
Hospital Charge Code	3207210001
Hospital Revenue Code	320
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

HC X-RAY LUMBAR SPINE 4 VW - XR LUMBAR SPINE COMPLETE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 72110
Hospital Charge Code	3207211001
Hospital Revenue Code	320
Min. Negotiated Rate	$32.35
Max. Negotiated Rate	$513.13
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$317.40
Rate for Payer: Cash Price	$317.40
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$32.35
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.97
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$32.35
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$108.35

Know your out-of-pocket cost for care.

All Charges