Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Calcaneus Right

Facility

$307.00

Service Code	HCPCS 73650 RT
Hospital Charge Code	1170034
Hospital Revenue Code	320
Min. Negotiated Rate	$17.03
Max. Negotiated Rate	$297.79
Rate for Payer: AlohaCare Medicaid	$153.50
Rate for Payer: AlohaCare Medicare	$153.50
Rate for Payer: Cash Price	$199.55
Rate for Payer: Cash Price	$199.55
Rate for Payer: Devoted Health Medicare	$168.85
Rate for Payer: Hawaii Medical Service Association ABD	$17.03
Rate for Payer: Hawaii Medical Service Association Medicare	$153.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.88
Rate for Payer: Hawaii Western Management Group Commercial	$291.65
Rate for Payer: Health Management Network Commercial	$260.95
Rate for Payer: Humana Medicare	$153.50
Rate for Payer: Kaiser Permanente Commercial	$276.30
Rate for Payer: Kaiser Permanente Medicaid	$156.57
Rate for Payer: Kaiser Permanente Medicare	$153.50
Rate for Payer: MDX Hawaii PPO	$297.79
Rate for Payer: Ohana Health Plan Medicaid	$153.50
Rate for Payer: Ohana Health Plan Medicare	$153.50
Rate for Payer: UnitedHealthcare Medicaid	$17.03
Rate for Payer: UnitedHealthcare Medicare	$153.50
Rate for Payer: University Health Alliance Commercial	$53.87

XR Calcaneus Right - Report

Professional

Both

$60.00

Service Code	HCPCS 73650 26,RT
Hospital Charge Code	629621
Hospital Revenue Code	972
Min. Negotiated Rate	$19.02
Max. Negotiated Rate	$51.00
Rate for Payer: AlohaCare Medicaid	$19.02
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Hawaii Western Management Group Commercial	$29.54
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Ohana Health Plan Medicaid	$19.02
Rate for Payer: UnitedHealthcare Medicaid	$19.02

XR Chest 1 View

Facility

$376.00

Service Code	HCPCS 71045
Hospital Charge Code	8102143
Hospital Revenue Code	324
Min. Negotiated Rate	$319.60
Max. Negotiated Rate	$364.72
Rate for Payer: Cash Price	$244.40
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Kaiser Permanente Commercial	$338.40
Rate for Payer: MDX Hawaii PPO	$364.72

XR Chest 1 View

Facility

$376.00

Service Code	HCPCS 71045
Hospital Charge Code	8102143
Hospital Revenue Code	324
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$364.72
Rate for Payer: AlohaCare Medicaid	$188.00
Rate for Payer: AlohaCare Medicare	$188.00
Rate for Payer: Cash Price	$244.40
Rate for Payer: Cash Price	$244.40
Rate for Payer: Devoted Health Medicare	$206.80
Rate for Payer: Hawaii Medical Service Association ABD	$15.78
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$188.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Humana Medicare	$188.00
Rate for Payer: Kaiser Permanente Commercial	$338.40
Rate for Payer: Kaiser Permanente Medicaid	$191.76
Rate for Payer: Kaiser Permanente Medicare	$188.00
Rate for Payer: MDX Hawaii PPO	$364.72
Rate for Payer: Ohana Health Plan Medicaid	$188.00
Rate for Payer: Ohana Health Plan Medicare	$188.00
Rate for Payer: UnitedHealthcare Medicaid	$16.90
Rate for Payer: UnitedHealthcare Medicare	$188.00
Rate for Payer: University Health Alliance Commercial	$40.29

XR Chest 1 View - Report

Professional

Both

$121.00

Service Code	HCPCS 71045 26
Hospital Charge Code	8102144
Hospital Revenue Code	972
Min. Negotiated Rate	$8.48
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$16.90
Rate for Payer: AlohaCare Medicare	$8.48
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$9.33
Rate for Payer: Hawaii Medical Service Association Medicare	$8.48
Rate for Payer: Hawaii Western Management Group Commercial	$34.57
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$9.33
Rate for Payer: Kaiser Permanente Medicaid	$9.33
Rate for Payer: Kaiser Permanente Medicare	$9.33
Rate for Payer: Ohana Health Plan Medicaid	$16.90
Rate for Payer: Ohana Health Plan Medicare	$8.48
Rate for Payer: UnitedHealthcare Medicaid	$16.90
Rate for Payer: UnitedHealthcare Medicare	$8.48

XR Chest 2 Views

Facility

$443.00

Service Code	HCPCS 71046
Hospital Charge Code	689607
Hospital Revenue Code	324
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$429.71
Rate for Payer: AlohaCare Medicaid	$221.50
Rate for Payer: AlohaCare Medicare	$221.50
Rate for Payer: Cash Price	$287.95
Rate for Payer: Cash Price	$287.95
Rate for Payer: Devoted Health Medicare	$243.65
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$221.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.07
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$376.55
Rate for Payer: Humana Medicare	$221.50
Rate for Payer: Kaiser Permanente Commercial	$398.70
Rate for Payer: Kaiser Permanente Medicaid	$225.93
Rate for Payer: Kaiser Permanente Medicare	$221.50
Rate for Payer: MDX Hawaii PPO	$429.71
Rate for Payer: Ohana Health Plan Medicaid	$221.50
Rate for Payer: Ohana Health Plan Medicare	$221.50
Rate for Payer: UnitedHealthcare Medicaid	$22.29
Rate for Payer: UnitedHealthcare Medicare	$221.50
Rate for Payer: University Health Alliance Commercial	$62.81

XR Chest 2 Views

Facility

$443.00

Service Code	HCPCS 71046
Hospital Charge Code	689607
Hospital Revenue Code	324
Min. Negotiated Rate	$376.55
Max. Negotiated Rate	$429.71
Rate for Payer: Cash Price	$287.95
Rate for Payer: Health Management Network Commercial	$376.55
Rate for Payer: Kaiser Permanente Commercial	$398.70
Rate for Payer: MDX Hawaii PPO	$429.71

XR Chest 2 Views - Report

Professional

Both

$121.00

Service Code	HCPCS 71046 26
Hospital Charge Code	629719
Hospital Revenue Code	972
Min. Negotiated Rate	$10.25
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$22.29
Rate for Payer: AlohaCare Medicare	$10.25
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$11.28
Rate for Payer: Hawaii Medical Service Association Medicare	$10.25
Rate for Payer: Hawaii Western Management Group Commercial	$39.25
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$11.28
Rate for Payer: Kaiser Permanente Medicaid	$11.28
Rate for Payer: Kaiser Permanente Medicare	$11.28
Rate for Payer: Ohana Health Plan Medicaid	$22.29
Rate for Payer: Ohana Health Plan Medicare	$10.25
Rate for Payer: UnitedHealthcare Medicaid	$22.29
Rate for Payer: UnitedHealthcare Medicare	$10.25

XR Chest 2 Views w/ Apical Lordotic

Facility

$565.00

Service Code	HCPCS 71047
Hospital Charge Code	1170040
Hospital Revenue Code	324
Min. Negotiated Rate	$480.25
Max. Negotiated Rate	$548.05
Rate for Payer: Cash Price	$367.25
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: MDX Hawaii PPO	$548.05

XR Chest 2 Views w/ Apical Lordotic

Facility

$565.00

Service Code	HCPCS 71047
Hospital Charge Code	1170040
Hospital Revenue Code	324
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$548.05
Rate for Payer: AlohaCare Medicaid	$282.50
Rate for Payer: AlohaCare Medicare	$282.50
Rate for Payer: Cash Price	$367.25
Rate for Payer: Cash Price	$367.25
Rate for Payer: Devoted Health Medicare	$310.75
Rate for Payer: Hawaii Medical Service Association ABD	$24.39
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$282.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.67
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$480.25
Rate for Payer: Humana Medicare	$282.50
Rate for Payer: Kaiser Permanente Commercial	$508.50
Rate for Payer: Kaiser Permanente Medicaid	$288.15
Rate for Payer: Kaiser Permanente Medicare	$282.50
Rate for Payer: MDX Hawaii PPO	$548.05
Rate for Payer: Ohana Health Plan Medicaid	$282.50
Rate for Payer: Ohana Health Plan Medicare	$282.50
Rate for Payer: UnitedHealthcare Medicaid	$28.11
Rate for Payer: UnitedHealthcare Medicare	$282.50
Rate for Payer: University Health Alliance Commercial	$80.64

XR Chest 2 Views w/ Apical Lordotic - Report

Professional

Both

$121.00

Service Code	HCPCS 71047 26
Hospital Charge Code	629721
Hospital Revenue Code	972
Min. Negotiated Rate	$13.06
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$28.11
Rate for Payer: AlohaCare Medicare	$13.06
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$14.37
Rate for Payer: Hawaii Medical Service Association Medicare	$13.06
Rate for Payer: Hawaii Western Management Group Commercial	$47.20
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$14.37
Rate for Payer: Kaiser Permanente Medicaid	$14.37
Rate for Payer: Kaiser Permanente Medicare	$14.37
Rate for Payer: Ohana Health Plan Medicaid	$28.11
Rate for Payer: Ohana Health Plan Medicare	$13.06
Rate for Payer: UnitedHealthcare Medicaid	$28.11
Rate for Payer: UnitedHealthcare Medicare	$13.06

XR Chest 4+ Views

Facility

$606.00

Service Code	HCPCS 71048
Hospital Charge Code	1170053
Hospital Revenue Code	324
Min. Negotiated Rate	$515.10
Max. Negotiated Rate	$587.82
Rate for Payer: Cash Price	$393.90
Rate for Payer: Health Management Network Commercial	$515.10
Rate for Payer: Kaiser Permanente Commercial	$545.40
Rate for Payer: MDX Hawaii PPO	$587.82

XR Chest 4+ Views

Facility

$606.00

Service Code	HCPCS 71048
Hospital Charge Code	1170053
Hospital Revenue Code	324
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$587.82
Rate for Payer: AlohaCare Medicaid	$303.00
Rate for Payer: AlohaCare Medicare	$303.00
Rate for Payer: Cash Price	$393.90
Rate for Payer: Cash Price	$393.90
Rate for Payer: Devoted Health Medicare	$333.30
Rate for Payer: Hawaii Medical Service Association ABD	$25.96
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$303.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.09
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$515.10
Rate for Payer: Humana Medicare	$303.00
Rate for Payer: Kaiser Permanente Commercial	$545.40
Rate for Payer: Kaiser Permanente Medicaid	$309.06
Rate for Payer: Kaiser Permanente Medicare	$303.00
Rate for Payer: MDX Hawaii PPO	$587.82
Rate for Payer: Ohana Health Plan Medicaid	$303.00
Rate for Payer: Ohana Health Plan Medicare	$303.00
Rate for Payer: UnitedHealthcare Medicaid	$30.28
Rate for Payer: UnitedHealthcare Medicare	$303.00
Rate for Payer: University Health Alliance Commercial	$86.36

XR Chest 4+ Views - Report

Professional

Both

$145.00

Service Code	HCPCS 71048 26
Hospital Charge Code	629727
Hospital Revenue Code	972
Min. Negotiated Rate	$14.96
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$30.28
Rate for Payer: AlohaCare Medicare	$14.96
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$16.46
Rate for Payer: Hawaii Medical Service Association Medicare	$14.96
Rate for Payer: Hawaii Western Management Group Commercial	$51.55
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$16.46
Rate for Payer: Kaiser Permanente Medicaid	$16.46
Rate for Payer: Kaiser Permanente Medicare	$16.46
Rate for Payer: Ohana Health Plan Medicaid	$30.28
Rate for Payer: Ohana Health Plan Medicare	$14.96
Rate for Payer: UnitedHealthcare Medicaid	$30.28
Rate for Payer: UnitedHealthcare Medicare	$14.96

XR Cholangiogram Injection Procedure

Facility

$8,004.00

Service Code	HCPCS 47531
Hospital Charge Code	2425440
Hospital Revenue Code	361
Min. Negotiated Rate	$6,803.40
Max. Negotiated Rate	$7,763.88
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Health Management Network Commercial	$6,803.40
Rate for Payer: Kaiser Permanente Commercial	$7,203.60
Rate for Payer: MDX Hawaii PPO	$7,763.88

XR Cholangiogram Injection Procedure

Facility

$8,004.00

Service Code	HCPCS 47531
Hospital Charge Code	2425440
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$7,763.88
Rate for Payer: AlohaCare Medicaid	$4,002.00
Rate for Payer: AlohaCare Medicare	$4,002.00
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Devoted Health Medicare	$4,402.20
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,002.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$6,803.40
Rate for Payer: Humana Medicare	$4,002.00
Rate for Payer: Kaiser Permanente Commercial	$7,203.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,002.00
Rate for Payer: MDX Hawaii PPO	$7,763.88
Rate for Payer: Ohana Health Plan Medicaid	$4,002.00
Rate for Payer: Ohana Health Plan Medicare	$4,002.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,002.00
Rate for Payer: University Health Alliance Commercial	$5,834.12

XR Cholangiogram Injection Procedure - Report

Professional

Both

$4,983.00

Service Code	HCPCS 47531
Hospital Charge Code	2425442
Hospital Revenue Code	972
Min. Negotiated Rate	$61.84
Max. Negotiated Rate	$4,235.55
Rate for Payer: AlohaCare Medicaid	$69.80
Rate for Payer: AlohaCare Medicare	$61.84
Rate for Payer: Cash Price	$3,238.95
Rate for Payer: Cash Price	$3,238.95
Rate for Payer: Devoted Health Medicare	$68.02
Rate for Payer: Hawaii Medical Service Association ABD	$69.80
Rate for Payer: Hawaii Medical Service Association Commercial	$152.70
Rate for Payer: Hawaii Medical Service Association Medicare	$61.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$69.80
Rate for Payer: Hawaii Western Management Group Commercial	$426.92
Rate for Payer: Health Management Network Commercial	$4,235.55
Rate for Payer: Kaiser Permanente Commercial	$68.02
Rate for Payer: Kaiser Permanente Medicaid	$68.02
Rate for Payer: Kaiser Permanente Medicare	$68.02
Rate for Payer: Ohana Health Plan Medicaid	$69.80
Rate for Payer: Ohana Health Plan Medicare	$61.84
Rate for Payer: UnitedHealthcare Medicaid	$69.80
Rate for Payer: UnitedHealthcare Medicare	$61.84
Rate for Payer: University Health Alliance Commercial	$87.08

XR Cholangiogram in OR

Facility

$617.00

Service Code	HCPCS 74300
Hospital Charge Code	1170065
Hospital Revenue Code	320
Min. Negotiated Rate	$524.45
Max. Negotiated Rate	$598.49
Rate for Payer: Cash Price	$401.05
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: MDX Hawaii PPO	$598.49

XR Cholangiogram in OR

Facility

$617.00

Service Code	HCPCS 74300
Hospital Charge Code	1170065
Hospital Revenue Code	320
Min. Negotiated Rate	$18.78
Max. Negotiated Rate	$598.49
Rate for Payer: AlohaCare Medicaid	$308.50
Rate for Payer: AlohaCare Medicare	$308.50
Rate for Payer: Cash Price	$401.05
Rate for Payer: Cash Price	$401.05
Rate for Payer: Devoted Health Medicare	$339.35
Rate for Payer: Hawaii Medical Service Association ABD	$18.78
Rate for Payer: Hawaii Medical Service Association Medicare	$308.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.20
Rate for Payer: Hawaii Western Management Group Commercial	$586.15
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Humana Medicare	$308.50
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: Kaiser Permanente Medicaid	$314.67
Rate for Payer: Kaiser Permanente Medicare	$308.50
Rate for Payer: MDX Hawaii PPO	$598.49
Rate for Payer: Ohana Health Plan Medicaid	$308.50
Rate for Payer: Ohana Health Plan Medicare	$308.50
Rate for Payer: UnitedHealthcare Medicaid	$18.78
Rate for Payer: UnitedHealthcare Medicare	$308.50
Rate for Payer: University Health Alliance Commercial	$449.73

XR Cholangiogram in OR - Report

Professional

Both

$50.00

Service Code	HCPCS 74300 26
Hospital Charge Code	629737
Hospital Revenue Code	972
Min. Negotiated Rate	$13.06
Max. Negotiated Rate	$42.50
Rate for Payer: AlohaCare Medicaid	$18.78
Rate for Payer: AlohaCare Medicare	$13.06
Rate for Payer: Cash Price	$32.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Devoted Health Medicare	$14.37
Rate for Payer: Hawaii Medical Service Association Medicare	$13.06
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Kaiser Permanente Commercial	$14.37
Rate for Payer: Kaiser Permanente Medicaid	$14.37
Rate for Payer: Kaiser Permanente Medicare	$14.37
Rate for Payer: Ohana Health Plan Medicaid	$18.78
Rate for Payer: Ohana Health Plan Medicare	$13.06
Rate for Payer: UnitedHealthcare Medicaid	$18.78
Rate for Payer: UnitedHealthcare Medicare	$13.06

XR Clavicle Bilat

Facility

$524.00

Service Code	HCPCS 73000 50
Hospital Charge Code	8211690
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$508.28
Rate for Payer: AlohaCare Medicaid	$262.00
Rate for Payer: AlohaCare Medicare	$262.00
Rate for Payer: Cash Price	$340.60
Rate for Payer: Cash Price	$340.60
Rate for Payer: Devoted Health Medicare	$288.20
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$497.80
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Humana Medicare	$262.00
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: Kaiser Permanente Medicaid	$267.24
Rate for Payer: Kaiser Permanente Medicare	$262.00
Rate for Payer: MDX Hawaii PPO	$508.28
Rate for Payer: Ohana Health Plan Medicaid	$262.00
Rate for Payer: Ohana Health Plan Medicare	$262.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Clavicle Bilat

Facility

$524.00

Service Code	HCPCS 73000 50
Hospital Charge Code	8211690
Hospital Revenue Code	320
Min. Negotiated Rate	$445.40
Max. Negotiated Rate	$508.28
Rate for Payer: Cash Price	$340.60
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: MDX Hawaii PPO	$508.28

XR Clavicle Bilat - Report

Professional

Both

$121.00

Service Code	HCPCS 73000 26,50
Hospital Charge Code	8211692
Hospital Revenue Code	972
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$21.78

XR Clavicle Left

Facility

$430.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	1170075
Hospital Revenue Code	320
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$279.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: MDX Hawaii PPO	$417.10

XR Clavicle Left

Facility

$430.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	1170075
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$417.10
Rate for Payer: AlohaCare Medicaid	$215.00
Rate for Payer: AlohaCare Medicare	$215.00
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$236.50
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$215.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Humana Medicare	$215.00
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: Kaiser Permanente Medicaid	$219.30
Rate for Payer: Kaiser Permanente Medicare	$215.00
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: Ohana Health Plan Medicaid	$215.00
Rate for Payer: Ohana Health Plan Medicare	$215.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$215.00
Rate for Payer: University Health Alliance Commercial	$56.28

Know your out-of-pocket cost for care.

All Charges