Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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	$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 6+ VW - XR LUMBAR SPINE 6+ VWS INCLUDING BENDING

Facility

$529.00

Service Code	HCPCS 72114
Hospital Charge Code	3207211401
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 6+ VW - XR LUMBAR SPINE 6+ VWS INCLUDING BENDING

Facility

$529.00

Service Code	HCPCS 72114
Hospital Charge Code	3207211401
Hospital Revenue Code	320
Min. Negotiated Rate	$39.30
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	$39.30
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	$42.37
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	$39.30
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$141.23

HC X-RAY LUMBAR SPINE FLEX/EXTEN - XR LUMBAR SPINE 4+ VIEWS W/ FLEX EXT

Facility

$529.00

Service Code	HCPCS 72120
Hospital Charge Code	3207212001
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 FLEX/EXTEN - XR LUMBAR SPINE 4+ VIEWS W/ FLEX EXT

Facility

$529.00

Service Code	HCPCS 72120
Hospital Charge Code	3207212001
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
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	$29.64
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	$32.30
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	$29.64
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$97.90

HC X-RAY NASAL BONES - XR NASAL BONES

Facility

$438.00

Service Code	HCPCS 70160
Hospital Charge Code	3207016001
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 NASAL BONES - XR NASAL BONES

Facility

$438.00

Service Code	HCPCS 70160
Hospital Charge Code	3207016001
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	$63.38

HC X-RAY NECK SOFT TISSUE - XR NECK SOFT TISSUE

Facility

$438.00

Service Code	HCPCS 70360
Hospital Charge Code	3207036001
Hospital Revenue Code	320
Min. Negotiated Rate	$15.15
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	$20.82
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	$15.15
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	$20.82
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$53.78

HC X-RAY NECK SOFT TISSUE - XR NECK SOFT TISSUE

Facility

$438.00

Service Code	HCPCS 70360
Hospital Charge Code	3207036001
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 NOSE-RECTUM CHILD F.B. - XR NOSE TO RECTUM FOREIGN BODY PEDS

Facility

$438.00

Service Code	HCPCS 76010
Hospital Charge Code	3207601001
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	$57.68

HC X-RAY NOSE-RECTUM CHILD F.B. - XR NOSE TO RECTUM FOREIGN BODY PEDS

Facility

$438.00

Service Code	HCPCS 76010
Hospital Charge Code	3207601001
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 OPER CHOLANGIOGRAM - XR CHOLANGIOGRAM INTRAOPERATIVE

Facility

$735.00

Service Code	HCPCS 74300
Hospital Charge Code	3207430001
Hospital Revenue Code	320
Min. Negotiated Rate	$624.75
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: MDX Hawaii PPO	$712.95

HC X-RAY OPER CHOLANGIOGRAM - XR CHOLANGIOGRAM INTRAOPERATIVE

Facility

$735.00

Service Code	HCPCS 74300
Hospital Charge Code	3207430001
Hospital Revenue Code	320
Min. Negotiated Rate	$18.78
Max. Negotiated Rate	$712.95
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Hawaii Medical Service Association ABD	$18.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.20
Rate for Payer: Hawaii Western Management Group Commercial	$698.25
Rate for Payer: Health Management Network Commercial	$624.75
Rate for Payer: Kaiser Permanente Commercial	$463.05
Rate for Payer: Kaiser Permanente Medicaid	$374.85
Rate for Payer: MDX Hawaii PPO	$712.95
Rate for Payer: UnitedHealthcare Medicaid	$18.78
Rate for Payer: University Health Alliance Commercial	$535.74

HC X-RAY ORBITS - XR ORBITS COMPLETE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 70200
Hospital Charge Code	3207020001
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
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	$25.96
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	$28.19
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	$25.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$90.41

HC X-RAY ORBITS - XR ORBITS COMPLETE 4+ VIEWS

Facility

$529.00

Service Code	HCPCS 70200
Hospital Charge Code	3207020001
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 PELVIS 1/2 VW - XR PELVIS 1-2 VIEWS

Facility

$529.00

Service Code	HCPCS 72170
Hospital Charge Code	3207217001
Hospital Revenue Code	320
Min. Negotiated Rate	$18.74
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	$18.74
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	$19.68
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	$18.74
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$55.37

HC X-RAY PELVIS 1/2 VW - XR PELVIS 1-2 VIEWS

Facility

$529.00

Service Code	HCPCS 72170
Hospital Charge Code	3207217001
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 PELVIS 3+ VW - XR PELVIS 3+ VIEWS

Facility

$529.00

Service Code	HCPCS 72190
Hospital Charge Code	3207219001
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 PELVIS 3+ VW - XR PELVIS 3+ VIEWS

Facility

$529.00

Service Code	HCPCS 72190
Hospital Charge Code	3207219001
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	$78.55

HC X-RAY PERITONEUM - CT GUIDED PERITONEOGRAM W CONTRAST

Facility

$2,137.00

Service Code	HCPCS 74190
Hospital Charge Code	3507419001
Hospital Revenue Code	350
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$2,072.89
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$645.50
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,346.31
Rate for Payer: Kaiser Permanente Medicaid	$1,089.87
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,072.89
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,557.66

HC X-RAY PERITONEUM - CT GUIDED PERITONEOGRAM W CONTRAST

Facility

$2,137.00

Service Code	HCPCS 74190
Hospital Charge Code	3507419001
Hospital Revenue Code	350
Min. Negotiated Rate	$1,816.45
Max. Negotiated Rate	$2,072.89
Rate for Payer: Cash Price	$1,282.20
Rate for Payer: Health Management Network Commercial	$1,816.45
Rate for Payer: MDX Hawaii PPO	$2,072.89

HC X-RAY RENAL CYST XLUMBAR+CONTRST - XR RENAL CYST LUMBAR W CONTRAST

Facility

$2,728.00

Service Code	HCPCS 74470
Hospital Charge Code	3207447001
Hospital Revenue Code	320
Min. Negotiated Rate	$2,318.80
Max. Negotiated Rate	$2,646.16
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: MDX Hawaii PPO	$2,646.16

HC X-RAY RENAL CYST XLUMBAR+CONTRST - XR RENAL CYST LUMBAR W CONTRAST

Facility

$2,728.00

Service Code	HCPCS 74470
Hospital Charge Code	3207447001
Hospital Revenue Code	320
Min. Negotiated Rate	$41.11
Max. Negotiated Rate	$2,646.16
Rate for Payer: AlohaCare Medicaid	$645.50
Rate for Payer: AlohaCare Medicare	$645.50
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Cash Price	$1,636.80
Rate for Payer: Devoted Health Medicare	$710.05
Rate for Payer: Hawaii Medical Service Association ABD	$41.11
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$645.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$44.72
Rate for Payer: Hawaii Western Management Group Commercial	$645.50
Rate for Payer: Health Management Network Commercial	$2,318.80
Rate for Payer: Humana Medicare	$645.50
Rate for Payer: Kaiser Permanente Commercial	$1,718.64
Rate for Payer: Kaiser Permanente Medicaid	$1,391.28
Rate for Payer: Kaiser Permanente Medicare	$645.50
Rate for Payer: MDX Hawaii PPO	$2,646.16
Rate for Payer: Ohana Health Plan Medicaid	$710.05
Rate for Payer: Ohana Health Plan Medicare	$645.50
Rate for Payer: UnitedHealthcare Medicaid	$41.11
Rate for Payer: UnitedHealthcare Medicare	$645.50
Rate for Payer: University Health Alliance Commercial	$1,988.44

HC X-RAY RETROGRADE PYELOGRAM - FL PYELOGRAM RETROGRADE

Facility

$1,776.00

Service Code	HCPCS 74420
Hospital Charge Code	3207442001
Hospital Revenue Code	320
Min. Negotiated Rate	$86.28
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	$86.28
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	$93.99
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	$86.28
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$159.90

HC X-RAY RETROGRADE PYELOGRAM - FL PYELOGRAM RETROGRADE

Facility

$1,776.00

Service Code	HCPCS 74420
Hospital Charge Code	3207442001
Hospital Revenue Code	320
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

Know your out-of-pocket cost for care.

All Charges