Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Myelogram Lumbosacral Spine

Facility

$1,585.00

Service Code	HCPCS 72265
Hospital Charge Code	1170321
Hospital Revenue Code	320
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$792.50
Rate for Payer: AlohaCare Medicare	$792.50
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Devoted Health Medicare	$871.75
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$792.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$800.90
Rate for Payer: Health Management Network Commercial	$1,347.25
Rate for Payer: Humana Medicare	$792.50
Rate for Payer: Kaiser Permanente Commercial	$1,426.50
Rate for Payer: Kaiser Permanente Medicaid	$808.35
Rate for Payer: Kaiser Permanente Medicare	$792.50
Rate for Payer: MDX Hawaii PPO	$1,537.45
Rate for Payer: Ohana Health Plan Medicaid	$792.50
Rate for Payer: Ohana Health Plan Medicare	$792.50
Rate for Payer: UnitedHealthcare Medicaid	$134.20
Rate for Payer: UnitedHealthcare Medicare	$792.50
Rate for Payer: University Health Alliance Commercial	$339.59

XR Myelogram Lumbosacral Spine

Facility

$1,585.00

Service Code	HCPCS 72265
Hospital Charge Code	1170321
Hospital Revenue Code	320
Min. Negotiated Rate	$1,347.25
Max. Negotiated Rate	$1,537.45
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Health Management Network Commercial	$1,347.25
Rate for Payer: Kaiser Permanente Commercial	$1,426.50
Rate for Payer: MDX Hawaii PPO	$1,537.45

XR Myelogram Lumbosacral Spine - Report

Professional

Both

$376.00

Service Code	HCPCS 72265 26
Hospital Charge Code	630316
Hospital Revenue Code	972
Min. Negotiated Rate	$40.93
Max. Negotiated Rate	$319.60
Rate for Payer: AlohaCare Medicaid	$71.98
Rate for Payer: AlohaCare Medicare	$40.93
Rate for Payer: Cash Price	$244.40
Rate for Payer: Cash Price	$244.40
Rate for Payer: Devoted Health Medicare	$45.02
Rate for Payer: Hawaii Medical Service Association Medicare	$40.93
Rate for Payer: Hawaii Western Management Group Commercial	$224.92
Rate for Payer: Health Management Network Commercial	$319.60
Rate for Payer: Kaiser Permanente Commercial	$45.02
Rate for Payer: Kaiser Permanente Medicaid	$45.02
Rate for Payer: Kaiser Permanente Medicare	$45.02
Rate for Payer: Ohana Health Plan Medicaid	$71.98
Rate for Payer: Ohana Health Plan Medicare	$40.93
Rate for Payer: UnitedHealthcare Medicaid	$71.98
Rate for Payer: UnitedHealthcare Medicare	$40.93

XR Myelogram Thoracic Spine

Facility

$1,585.00

Service Code	HCPCS 72255
Hospital Charge Code	1170327
Hospital Revenue Code	320
Min. Negotiated Rate	$142.62
Max. Negotiated Rate	$1,537.45
Rate for Payer: AlohaCare Medicaid	$792.50
Rate for Payer: AlohaCare Medicare	$792.50
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Devoted Health Medicare	$871.75
Rate for Payer: Hawaii Medical Service Association ABD	$142.62
Rate for Payer: Hawaii Medical Service Association Commercial	$1,001.12
Rate for Payer: Hawaii Medical Service Association Medicare	$792.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$149.75
Rate for Payer: Hawaii Western Management Group Commercial	$800.90
Rate for Payer: Health Management Network Commercial	$1,347.25
Rate for Payer: Humana Medicare	$792.50
Rate for Payer: Kaiser Permanente Commercial	$1,426.50
Rate for Payer: Kaiser Permanente Medicaid	$808.35
Rate for Payer: Kaiser Permanente Medicare	$792.50
Rate for Payer: MDX Hawaii PPO	$1,537.45
Rate for Payer: Ohana Health Plan Medicaid	$792.50
Rate for Payer: Ohana Health Plan Medicare	$792.50
Rate for Payer: UnitedHealthcare Medicaid	$142.62
Rate for Payer: UnitedHealthcare Medicare	$792.50
Rate for Payer: University Health Alliance Commercial	$344.53

XR Myelogram Thoracic Spine

Facility

$1,585.00

Service Code	HCPCS 72255
Hospital Charge Code	1170327
Hospital Revenue Code	320
Min. Negotiated Rate	$1,347.25
Max. Negotiated Rate	$1,537.45
Rate for Payer: Cash Price	$1,030.25
Rate for Payer: Health Management Network Commercial	$1,347.25
Rate for Payer: Kaiser Permanente Commercial	$1,426.50
Rate for Payer: MDX Hawaii PPO	$1,537.45

XR Myelogram Thoracic Spine - Report

Professional

Both

$675.00

Service Code	HCPCS 72255 26
Hospital Charge Code	630312
Hospital Revenue Code	972
Min. Negotiated Rate	$42.85
Max. Negotiated Rate	$573.75
Rate for Payer: AlohaCare Medicaid	$70.71
Rate for Payer: AlohaCare Medicare	$42.85
Rate for Payer: Cash Price	$438.75
Rate for Payer: Cash Price	$438.75
Rate for Payer: Devoted Health Medicare	$47.13
Rate for Payer: Hawaii Medical Service Association Medicare	$42.85
Rate for Payer: Hawaii Western Management Group Commercial	$239.92
Rate for Payer: Health Management Network Commercial	$573.75
Rate for Payer: Kaiser Permanente Commercial	$47.13
Rate for Payer: Kaiser Permanente Medicaid	$47.13
Rate for Payer: Kaiser Permanente Medicare	$47.13
Rate for Payer: Ohana Health Plan Medicaid	$70.71
Rate for Payer: Ohana Health Plan Medicare	$42.85
Rate for Payer: UnitedHealthcare Medicaid	$70.71
Rate for Payer: UnitedHealthcare Medicare	$42.85

XR Nasal Bones 3+ Views

Facility

$417.00

Service Code	HCPCS 70160
Hospital Charge Code	1170329
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$404.49
Rate for Payer: AlohaCare Medicaid	$208.50
Rate for Payer: AlohaCare Medicare	$208.50
Rate for Payer: Cash Price	$271.05
Rate for Payer: Cash Price	$271.05
Rate for Payer: Devoted Health Medicare	$229.35
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$208.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$354.45
Rate for Payer: Humana Medicare	$208.50
Rate for Payer: Kaiser Permanente Commercial	$375.30
Rate for Payer: Kaiser Permanente Medicaid	$212.67
Rate for Payer: Kaiser Permanente Medicare	$208.50
Rate for Payer: MDX Hawaii PPO	$404.49
Rate for Payer: Ohana Health Plan Medicaid	$208.50
Rate for Payer: Ohana Health Plan Medicare	$208.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$208.50
Rate for Payer: University Health Alliance Commercial	$63.38

XR Nasal Bones 3+ Views

Facility

$417.00

Service Code	HCPCS 70160
Hospital Charge Code	1170329
Hospital Revenue Code	320
Min. Negotiated Rate	$354.45
Max. Negotiated Rate	$404.49
Rate for Payer: Cash Price	$271.05
Rate for Payer: Health Management Network Commercial	$354.45
Rate for Payer: Kaiser Permanente Commercial	$375.30
Rate for Payer: MDX Hawaii PPO	$404.49

XR Nasal Bones 3+ Views - Report

Professional

Both

$66.00

Service Code	HCPCS 70160 26
Hospital Charge Code	630310
Hospital Revenue Code	972
Min. Negotiated Rate	$8.53
Max. Negotiated Rate	$56.10
Rate for Payer: AlohaCare Medicaid	$25.19
Rate for Payer: AlohaCare Medicare	$8.53
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$9.38
Rate for Payer: Hawaii Medical Service Association Medicare	$8.53
Rate for Payer: Hawaii Western Management Group Commercial	$32.36
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Kaiser Permanente Commercial	$9.38
Rate for Payer: Kaiser Permanente Medicaid	$9.38
Rate for Payer: Kaiser Permanente Medicare	$9.38
Rate for Payer: Ohana Health Plan Medicaid	$25.19
Rate for Payer: Ohana Health Plan Medicare	$8.53
Rate for Payer: UnitedHealthcare Medicaid	$25.19
Rate for Payer: UnitedHealthcare Medicare	$8.53

XR Neck Soft Tissue

Facility

$363.00

Service Code	HCPCS 70360
Hospital Charge Code	1170331
Hospital Revenue Code	320
Min. Negotiated Rate	$308.55
Max. Negotiated Rate	$352.11
Rate for Payer: Cash Price	$235.95
Rate for Payer: Health Management Network Commercial	$308.55
Rate for Payer: Kaiser Permanente Commercial	$326.70
Rate for Payer: MDX Hawaii PPO	$352.11

XR Neck Soft Tissue

Facility

$363.00

Service Code	HCPCS 70360
Hospital Charge Code	1170331
Hospital Revenue Code	320
Min. Negotiated Rate	$15.15
Max. Negotiated Rate	$352.11
Rate for Payer: AlohaCare Medicaid	$181.50
Rate for Payer: AlohaCare Medicare	$181.50
Rate for Payer: Cash Price	$235.95
Rate for Payer: Cash Price	$235.95
Rate for Payer: Devoted Health Medicare	$199.65
Rate for Payer: Hawaii Medical Service Association ABD	$20.82
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$181.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.15
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$308.55
Rate for Payer: Humana Medicare	$181.50
Rate for Payer: Kaiser Permanente Commercial	$326.70
Rate for Payer: Kaiser Permanente Medicaid	$185.13
Rate for Payer: Kaiser Permanente Medicare	$181.50
Rate for Payer: MDX Hawaii PPO	$352.11
Rate for Payer: Ohana Health Plan Medicaid	$181.50
Rate for Payer: Ohana Health Plan Medicare	$181.50
Rate for Payer: UnitedHealthcare Medicaid	$20.82
Rate for Payer: UnitedHealthcare Medicare	$181.50
Rate for Payer: University Health Alliance Commercial	$53.78

XR Neck Soft Tissue - Report

Professional

Both

$60.00

Service Code	HCPCS 70360 26
Hospital Charge Code	630308
Hospital Revenue Code	972
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$51.00
Rate for Payer: Kaiser Permanente Commercial	$9.75
Rate for Payer: AlohaCare Medicaid	$20.80
Rate for Payer: AlohaCare Medicare	$8.86
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Devoted Health Medicare	$9.75
Rate for Payer: Hawaii Medical Service Association Medicare	$8.86
Rate for Payer: Hawaii Western Management Group Commercial	$27.84
Rate for Payer: Health Management Network Commercial	$51.00
Rate for Payer: Kaiser Permanente Medicaid	$9.75
Rate for Payer: Kaiser Permanente Medicare	$9.75
Rate for Payer: Ohana Health Plan Medicaid	$20.80
Rate for Payer: Ohana Health Plan Medicare	$8.86
Rate for Payer: UnitedHealthcare Medicaid	$20.80
Rate for Payer: UnitedHealthcare Medicare	$8.86

XR Orbits Complete

Facility

$488.00

Service Code	HCPCS 70200
Hospital Charge Code	1170339
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$473.36
Rate for Payer: AlohaCare Medicaid	$244.00
Rate for Payer: AlohaCare Medicare	$244.00
Rate for Payer: Cash Price	$317.20
Rate for Payer: Cash Price	$317.20
Rate for Payer: Devoted Health Medicare	$268.40
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	$244.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.19
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Humana Medicare	$244.00
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: Kaiser Permanente Medicare	$244.00
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: Ohana Health Plan Medicaid	$244.00
Rate for Payer: Ohana Health Plan Medicare	$244.00
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$244.00
Rate for Payer: University Health Alliance Commercial	$90.41

XR Orbits Complete

Facility

$488.00

Service Code	HCPCS 70200
Hospital Charge Code	1170339
Hospital Revenue Code	320
Min. Negotiated Rate	$414.80
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$317.20
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$439.20
Rate for Payer: MDX Hawaii PPO	$473.36

XR Orbits Complete - Report

Professional

Both

$132.00

Service Code	HCPCS 70200 26
Hospital Charge Code	630300
Hospital Revenue Code	972
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$112.20
Rate for Payer: AlohaCare Medicaid	$31.98
Rate for Payer: AlohaCare Medicare	$13.39
Rate for Payer: Cash Price	$85.80
Rate for Payer: Cash Price	$85.80
Rate for Payer: Devoted Health Medicare	$14.73
Rate for Payer: Hawaii Medical Service Association Medicare	$13.39
Rate for Payer: Hawaii Western Management Group Commercial	$50.11
Rate for Payer: Health Management Network Commercial	$112.20
Rate for Payer: Kaiser Permanente Commercial	$14.73
Rate for Payer: Kaiser Permanente Medicaid	$14.73
Rate for Payer: Kaiser Permanente Medicare	$14.73
Rate for Payer: Ohana Health Plan Medicaid	$31.98
Rate for Payer: Ohana Health Plan Medicare	$13.39
Rate for Payer: UnitedHealthcare Medicaid	$31.98
Rate for Payer: UnitedHealthcare Medicare	$13.39

XR Osseous Survey Complete

Facility

$746.00

Service Code	HCPCS 77075
Hospital Charge Code	1170018
Hospital Revenue Code	320
Min. Negotiated Rate	$634.10
Max. Negotiated Rate	$723.62
Rate for Payer: Cash Price	$484.90
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: MDX Hawaii PPO	$723.62

XR Osseous Survey Complete

Facility

$746.00

Service Code	HCPCS 77075
Hospital Charge Code	1170018
Hospital Revenue Code	320
Min. Negotiated Rate	$48.32
Max. Negotiated Rate	$723.62
Rate for Payer: AlohaCare Medicaid	$373.00
Rate for Payer: AlohaCare Medicare	$373.00
Rate for Payer: Cash Price	$484.90
Rate for Payer: Cash Price	$484.90
Rate for Payer: Devoted Health Medicare	$410.30
Rate for Payer: Hawaii Medical Service Association ABD	$48.32
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$373.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.58
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$634.10
Rate for Payer: Humana Medicare	$373.00
Rate for Payer: Kaiser Permanente Commercial	$671.40
Rate for Payer: Kaiser Permanente Medicaid	$380.46
Rate for Payer: Kaiser Permanente Medicare	$373.00
Rate for Payer: MDX Hawaii PPO	$723.62
Rate for Payer: Ohana Health Plan Medicaid	$373.00
Rate for Payer: Ohana Health Plan Medicare	$373.00
Rate for Payer: UnitedHealthcare Medicaid	$48.32
Rate for Payer: UnitedHealthcare Medicare	$373.00
Rate for Payer: University Health Alliance Commercial	$195.99

XR Osseous Survey Complete - Report

Professional

Both

$136.00

Service Code	HCPCS 77075 26
Hospital Charge Code	627659
Hospital Revenue Code	972
Min. Negotiated Rate	$26.21
Max. Negotiated Rate	$115.60
Rate for Payer: AlohaCare Medicaid	$66.39
Rate for Payer: AlohaCare Medicare	$26.21
Rate for Payer: Cash Price	$88.40
Rate for Payer: Cash Price	$88.40
Rate for Payer: Devoted Health Medicare	$28.83
Rate for Payer: Hawaii Medical Service Association Medicare	$26.21
Rate for Payer: Hawaii Western Management Group Commercial	$105.93
Rate for Payer: Health Management Network Commercial	$115.60
Rate for Payer: Kaiser Permanente Commercial	$28.83
Rate for Payer: Kaiser Permanente Medicaid	$28.83
Rate for Payer: Kaiser Permanente Medicare	$28.83
Rate for Payer: Ohana Health Plan Medicaid	$66.39
Rate for Payer: Ohana Health Plan Medicare	$26.21
Rate for Payer: UnitedHealthcare Medicaid	$66.39
Rate for Payer: UnitedHealthcare Medicare	$26.21

XR Osseous Survey Infant

Facility

$580.00

Service Code	HCPCS 77076
Hospital Charge Code	1170020
Hospital Revenue Code	320
Min. Negotiated Rate	$29.05
Max. Negotiated Rate	$562.60
Rate for Payer: AlohaCare Medicaid	$290.00
Rate for Payer: AlohaCare Medicare	$290.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Cash Price	$377.00
Rate for Payer: Devoted Health Medicare	$319.00
Rate for Payer: Hawaii Medical Service Association ABD	$29.98
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$290.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.05
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Humana Medicare	$290.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: Kaiser Permanente Medicaid	$295.80
Rate for Payer: Kaiser Permanente Medicare	$290.00
Rate for Payer: MDX Hawaii PPO	$562.60
Rate for Payer: Ohana Health Plan Medicaid	$290.00
Rate for Payer: Ohana Health Plan Medicare	$290.00
Rate for Payer: UnitedHealthcare Medicaid	$29.98
Rate for Payer: UnitedHealthcare Medicare	$290.00
Rate for Payer: University Health Alliance Commercial	$155.46

XR Osseous Survey Infant

Facility

$580.00

Service Code	HCPCS 77076
Hospital Charge Code	1170020
Hospital Revenue Code	320
Min. Negotiated Rate	$493.00
Max. Negotiated Rate	$562.60
Rate for Payer: Cash Price	$377.00
Rate for Payer: Health Management Network Commercial	$493.00
Rate for Payer: Kaiser Permanente Commercial	$522.00
Rate for Payer: MDX Hawaii PPO	$562.60

XR Osseous Survey Infant - Report

Professional

Both

$146.00

Service Code	HCPCS 77076 26
Hospital Charge Code	627661
Hospital Revenue Code	972
Min. Negotiated Rate	$32.98
Max. Negotiated Rate	$124.10
Rate for Payer: AlohaCare Medicaid	$71.11
Rate for Payer: AlohaCare Medicare	$32.98
Rate for Payer: Cash Price	$94.90
Rate for Payer: Cash Price	$94.90
Rate for Payer: Devoted Health Medicare	$36.28
Rate for Payer: Hawaii Medical Service Association Medicare	$32.98
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$36.28
Rate for Payer: Kaiser Permanente Medicaid	$36.28
Rate for Payer: Kaiser Permanente Medicare	$36.28
Rate for Payer: Ohana Health Plan Medicaid	$71.11
Rate for Payer: Ohana Health Plan Medicare	$32.98
Rate for Payer: UnitedHealthcare Medicaid	$71.11
Rate for Payer: UnitedHealthcare Medicare	$32.98

XR Osseous Survey Limited

Facility

$536.00

Service Code	HCPCS 77074
Hospital Charge Code	1170022
Hospital Revenue Code	320
Min. Negotiated Rate	$455.60
Max. Negotiated Rate	$519.92
Rate for Payer: Cash Price	$348.40
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: MDX Hawaii PPO	$519.92

XR Osseous Survey Limited

Facility

$536.00

Service Code	HCPCS 77074
Hospital Charge Code	1170022
Hospital Revenue Code	320
Min. Negotiated Rate	$32.26
Max. Negotiated Rate	$519.92
Rate for Payer: AlohaCare Medicaid	$268.00
Rate for Payer: AlohaCare Medicare	$268.00
Rate for Payer: Cash Price	$348.40
Rate for Payer: Cash Price	$348.40
Rate for Payer: Devoted Health Medicare	$294.80
Rate for Payer: Hawaii Medical Service Association ABD	$32.26
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$268.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$36.10
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$455.60
Rate for Payer: Humana Medicare	$268.00
Rate for Payer: Kaiser Permanente Commercial	$482.40
Rate for Payer: Kaiser Permanente Medicaid	$273.36
Rate for Payer: Kaiser Permanente Medicare	$268.00
Rate for Payer: MDX Hawaii PPO	$519.92
Rate for Payer: Ohana Health Plan Medicaid	$268.00
Rate for Payer: Ohana Health Plan Medicare	$268.00
Rate for Payer: UnitedHealthcare Medicaid	$32.26
Rate for Payer: UnitedHealthcare Medicare	$268.00
Rate for Payer: University Health Alliance Commercial	$136.46

XR Osseous Survey Limited - Report

Professional

Both

$145.00

Service Code	HCPCS 77074 26
Hospital Charge Code	627663
Hospital Revenue Code	972
Min. Negotiated Rate	$21.02
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$43.32
Rate for Payer: AlohaCare Medicare	$21.02
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$23.12
Rate for Payer: Hawaii Medical Service Association Medicare	$21.02
Rate for Payer: Hawaii Western Management Group Commercial	$73.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$23.12
Rate for Payer: Kaiser Permanente Medicaid	$23.12
Rate for Payer: Kaiser Permanente Medicare	$23.12
Rate for Payer: Ohana Health Plan Medicaid	$43.32
Rate for Payer: Ohana Health Plan Medicare	$21.02
Rate for Payer: UnitedHealthcare Medicaid	$43.32
Rate for Payer: UnitedHealthcare Medicare	$21.02

XR Pelvis 1 or 2 Views

Facility

$386.00

Service Code	HCPCS 72170
Hospital Charge Code	1170351
Hospital Revenue Code	320
Min. Negotiated Rate	$328.10
Max. Negotiated Rate	$374.42
Rate for Payer: Cash Price	$250.90
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: MDX Hawaii PPO	$374.42

Know your out-of-pocket cost for care.

All Charges