Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

PAIN & SPINE LEAD 3888-33 PISCES QUAD PLUS 33CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806207
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE LEAD 3888-45 PISCES QUAD PLUS 45CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806208
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.50
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE LEAD 3888-45 PISCES QUAD PLUS 45CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806208
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE LEAD 3888-56 PISCES QUAD PLUS 56CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806209
Hospital Revenue Code	278
Min. Negotiated Rate	$1,492.50
Max. Negotiated Rate	$2,895.45
Rate for Payer: AlohaCare Medicaid	$1,492.50
Rate for Payer: AlohaCare Medicare	$1,492.50
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Devoted Health Medicare	$1,641.75
Rate for Payer: Hawaii Medical Service Association Medicare	$1,492.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Humana Medicare	$1,492.50
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: Kaiser Permanente Medicaid	$1,522.35
Rate for Payer: Kaiser Permanente Medicare	$1,492.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: Ohana Health Plan Medicaid	$1,492.50
Rate for Payer: Ohana Health Plan Medicare	$1,492.50
Rate for Payer: UnitedHealthcare Medicare	$1,492.50
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE LEAD 3888-56 PISCES QUAD PLUS 56CM

Facility

$2,985.00

Service Code	HCPCS C1778
Hospital Charge Code	8806209
Hospital Revenue Code	278
Min. Negotiated Rate	$1,671.60
Max. Negotiated Rate	$2,895.45
Rate for Payer: Cash Price	$1,940.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,089.50
Rate for Payer: Health Management Network Commercial	$2,537.25
Rate for Payer: Kaiser Permanente Commercial	$2,686.50
Rate for Payer: MDX Hawaii PPO	$2,895.45
Rate for Payer: University Health Alliance Commercial	$1,671.60

PAIN & SPINE LEAD 977A160 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806225
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A160 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806225
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A175 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806226
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A175 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806226
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A190 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806227
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A190 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806227
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A260 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806228
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A260 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806228
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A275 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806229
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A275 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806229
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A290 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806230
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977A290 3MM SUBCOMPACT 1X8 MRI

Facility

$4,400.00

Service Code	HCPCS C1778
Hospital Charge Code	8806230
Hospital Revenue Code	278
Min. Negotiated Rate	$2,200.00
Max. Negotiated Rate	$4,268.00
Rate for Payer: AlohaCare Medicaid	$2,200.00
Rate for Payer: AlohaCare Medicare	$2,200.00
Rate for Payer: Cash Price	$2,860.00
Rate for Payer: Devoted Health Medicare	$2,420.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,080.00
Rate for Payer: Health Management Network Commercial	$3,740.00
Rate for Payer: Humana Medicare	$2,200.00
Rate for Payer: Kaiser Permanente Commercial	$3,960.00
Rate for Payer: Kaiser Permanente Medicaid	$2,244.00
Rate for Payer: Kaiser Permanente Medicare	$2,200.00
Rate for Payer: MDX Hawaii PPO	$4,268.00
Rate for Payer: Ohana Health Plan Medicaid	$2,200.00
Rate for Payer: Ohana Health Plan Medicare	$2,200.00
Rate for Payer: UnitedHealthcare Medicare	$2,200.00
Rate for Payer: University Health Alliance Commercial	$2,464.00

PAIN & SPINE LEAD 977C165 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806210
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C165 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806210
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C190 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806211
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C190 SPECIFY SURESCAN MRI 5-6-5

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806211
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C265 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806212
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C265 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806212
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C290 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806213
Hospital Revenue Code	278
Min. Negotiated Rate	$7,000.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: AlohaCare Medicaid	$7,000.00
Rate for Payer: AlohaCare Medicare	$7,000.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Devoted Health Medicare	$7,700.00
Rate for Payer: Hawaii Medical Service Association Medicare	$7,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Humana Medicare	$7,000.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: Kaiser Permanente Medicaid	$7,140.00
Rate for Payer: Kaiser Permanente Medicare	$7,000.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: Ohana Health Plan Medicaid	$7,000.00
Rate for Payer: Ohana Health Plan Medicare	$7,000.00
Rate for Payer: UnitedHealthcare Medicare	$7,000.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

PAIN & SPINE LEAD 977C290 SPECIFY SURESCAN MRI 2X8

Facility

$14,000.00

Service Code	HCPCS C1778
Hospital Charge Code	8806213
Hospital Revenue Code	278
Min. Negotiated Rate	$7,840.00
Max. Negotiated Rate	$13,580.00
Rate for Payer: Cash Price	$9,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,800.00
Rate for Payer: Health Management Network Commercial	$11,900.00
Rate for Payer: Kaiser Permanente Commercial	$12,600.00
Rate for Payer: MDX Hawaii PPO	$13,580.00
Rate for Payer: University Health Alliance Commercial	$7,840.00

Know your out-of-pocket cost for care.

All Charges