Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Pelvis 1 or 2 Views

Facility

$386.00

Service Code	HCPCS 72170
Hospital Charge Code	1170351
Hospital Revenue Code	320
Min. Negotiated Rate	$18.74
Max. Negotiated Rate	$374.42
Rate for Payer: AlohaCare Medicaid	$193.00
Rate for Payer: AlohaCare Medicare	$193.00
Rate for Payer: Cash Price	$250.90
Rate for Payer: Cash Price	$250.90
Rate for Payer: Devoted Health Medicare	$212.30
Rate for Payer: Hawaii Medical Service Association ABD	$18.74
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$193.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.68
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$328.10
Rate for Payer: Humana Medicare	$193.00
Rate for Payer: Kaiser Permanente Commercial	$347.40
Rate for Payer: Kaiser Permanente Medicaid	$196.86
Rate for Payer: Kaiser Permanente Medicare	$193.00
Rate for Payer: MDX Hawaii PPO	$374.42
Rate for Payer: Ohana Health Plan Medicaid	$193.00
Rate for Payer: Ohana Health Plan Medicare	$193.00
Rate for Payer: UnitedHealthcare Medicaid	$18.74
Rate for Payer: UnitedHealthcare Medicare	$193.00
Rate for Payer: University Health Alliance Commercial	$55.37

XR Pelvis 1 or 2 Views - Report

Professional

Both

$70.00

Service Code	HCPCS 72170 26
Hospital Charge Code	630286
Hospital Revenue Code	972
Min. Negotiated Rate	$8.53
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$18.54
Rate for Payer: AlohaCare Medicare	$8.53
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
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	$32.05
Rate for Payer: Health Management Network Commercial	$59.50
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	$18.54
Rate for Payer: Ohana Health Plan Medicare	$8.53
Rate for Payer: UnitedHealthcare Medicaid	$18.54
Rate for Payer: UnitedHealthcare Medicare	$8.53

XR Pelvis Complete 3+ Views

Facility

$548.00

Service Code	HCPCS 72190
Hospital Charge Code	1170353
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$531.56
Rate for Payer: AlohaCare Medicaid	$274.00
Rate for Payer: AlohaCare Medicare	$274.00
Rate for Payer: Cash Price	$356.20
Rate for Payer: Cash Price	$356.20
Rate for Payer: Devoted Health Medicare	$301.40
Rate for Payer: Hawaii Medical Service Association ABD	$21.96
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$274.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$465.80
Rate for Payer: Humana Medicare	$274.00
Rate for Payer: Kaiser Permanente Commercial	$493.20
Rate for Payer: Kaiser Permanente Medicaid	$279.48
Rate for Payer: Kaiser Permanente Medicare	$274.00
Rate for Payer: MDX Hawaii PPO	$531.56
Rate for Payer: Ohana Health Plan Medicaid	$274.00
Rate for Payer: Ohana Health Plan Medicare	$274.00
Rate for Payer: UnitedHealthcare Medicaid	$21.96
Rate for Payer: UnitedHealthcare Medicare	$274.00
Rate for Payer: University Health Alliance Commercial	$78.55

XR Pelvis Complete 3+ Views

Facility

$548.00

Service Code	HCPCS 72190
Hospital Charge Code	1170353
Hospital Revenue Code	320
Min. Negotiated Rate	$465.80
Max. Negotiated Rate	$531.56
Rate for Payer: Cash Price	$356.20
Rate for Payer: Health Management Network Commercial	$465.80
Rate for Payer: Kaiser Permanente Commercial	$493.20
Rate for Payer: MDX Hawaii PPO	$531.56

XR Pelvis Complete 3+ Views - Report

Professional

Both

$76.00

Service Code	HCPCS 72190 26
Hospital Charge Code	630282
Hospital Revenue Code	972
Min. Negotiated Rate	$12.58
Max. Negotiated Rate	$64.60
Rate for Payer: AlohaCare Medicaid	$28.17
Rate for Payer: AlohaCare Medicare	$12.58
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$13.84
Rate for Payer: Hawaii Medical Service Association Medicare	$12.58
Rate for Payer: Hawaii Western Management Group Commercial	$41.06
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$13.84
Rate for Payer: Kaiser Permanente Medicaid	$13.84
Rate for Payer: Kaiser Permanente Medicare	$13.84
Rate for Payer: Ohana Health Plan Medicaid	$28.17
Rate for Payer: Ohana Health Plan Medicare	$12.58
Rate for Payer: UnitedHealthcare Medicaid	$28.17
Rate for Payer: UnitedHealthcare Medicare	$12.58

XR Ribs 2 Views Left

Facility

$431.00

Service Code	HCPCS 71100 LT
Hospital Charge Code	1170371
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$418.07
Rate for Payer: AlohaCare Medicaid	$215.50
Rate for Payer: AlohaCare Medicare	$215.50
Rate for Payer: Cash Price	$280.15
Rate for Payer: Cash Price	$280.15
Rate for Payer: Devoted Health Medicare	$237.05
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Medicare	$215.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$409.45
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Humana Medicare	$215.50
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: Kaiser Permanente Medicaid	$219.81
Rate for Payer: Kaiser Permanente Medicare	$215.50
Rate for Payer: MDX Hawaii PPO	$418.07
Rate for Payer: Ohana Health Plan Medicaid	$215.50
Rate for Payer: Ohana Health Plan Medicare	$215.50
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$215.50
Rate for Payer: University Health Alliance Commercial	$66.43

XR Ribs 2 Views Left

Facility

$431.00

Service Code	HCPCS 71100 LT
Hospital Charge Code	1170371
Hospital Revenue Code	320
Min. Negotiated Rate	$366.35
Max. Negotiated Rate	$418.07
Rate for Payer: Cash Price	$280.15
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: MDX Hawaii PPO	$418.07

XR Ribs 2 Views Left - Report

Professional

Both

$82.00

Service Code	HCPCS 71100 26,LT
Hospital Charge Code	630230
Hospital Revenue Code	972
Min. Negotiated Rate	$24.35
Max. Negotiated Rate	$69.70
Rate for Payer: AlohaCare Medicaid	$24.35
Rate for Payer: Cash Price	$53.30
Rate for Payer: Cash Price	$53.30
Rate for Payer: Hawaii Western Management Group Commercial	$37.53
Rate for Payer: Health Management Network Commercial	$69.70
Rate for Payer: Ohana Health Plan Medicaid	$24.35
Rate for Payer: UnitedHealthcare Medicaid	$24.35

XR Ribs 2 Views Right

Facility

$431.00

Service Code	HCPCS 71100 RT
Hospital Charge Code	1170373
Hospital Revenue Code	320
Min. Negotiated Rate	$366.35
Max. Negotiated Rate	$418.07
Rate for Payer: Cash Price	$280.15
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: MDX Hawaii PPO	$418.07

XR Ribs 2 Views Right

Facility

$431.00

Service Code	HCPCS 71100 RT
Hospital Charge Code	1170373
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$418.07
Rate for Payer: AlohaCare Medicaid	$215.50
Rate for Payer: AlohaCare Medicare	$215.50
Rate for Payer: Cash Price	$280.15
Rate for Payer: Cash Price	$280.15
Rate for Payer: Devoted Health Medicare	$237.05
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Medicare	$215.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$409.45
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Humana Medicare	$215.50
Rate for Payer: Kaiser Permanente Commercial	$387.90
Rate for Payer: Kaiser Permanente Medicaid	$219.81
Rate for Payer: Kaiser Permanente Medicare	$215.50
Rate for Payer: MDX Hawaii PPO	$418.07
Rate for Payer: Ohana Health Plan Medicaid	$215.50
Rate for Payer: Ohana Health Plan Medicare	$215.50
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$215.50
Rate for Payer: University Health Alliance Commercial	$66.43

XR Ribs 2 Views Right - Report

Professional

Both

$121.00

Service Code	HCPCS 71100 26,RT
Hospital Charge Code	630228
Hospital Revenue Code	972
Min. Negotiated Rate	$24.35
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$24.35
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$37.53
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$24.35
Rate for Payer: UnitedHealthcare Medicaid	$24.35

XR Ribs 3 Views Bilateral

Facility

$578.00

Service Code	HCPCS 71110
Hospital Charge Code	1170375
Hospital Revenue Code	320
Min. Negotiated Rate	$491.30
Max. Negotiated Rate	$560.66
Rate for Payer: Cash Price	$375.70
Rate for Payer: Health Management Network Commercial	$491.30
Rate for Payer: Kaiser Permanente Commercial	$520.20
Rate for Payer: MDX Hawaii PPO	$560.66

XR Ribs 3 Views Bilateral

Facility

$578.00

Service Code	HCPCS 71110
Hospital Charge Code	1170375
Hospital Revenue Code	320
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$560.66
Rate for Payer: AlohaCare Medicaid	$289.00
Rate for Payer: AlohaCare Medicare	$289.00
Rate for Payer: Cash Price	$375.70
Rate for Payer: Cash Price	$375.70
Rate for Payer: Devoted Health Medicare	$317.90
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	$289.00
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	$491.30
Rate for Payer: Humana Medicare	$289.00
Rate for Payer: Kaiser Permanente Commercial	$520.20
Rate for Payer: Kaiser Permanente Medicaid	$294.78
Rate for Payer: Kaiser Permanente Medicare	$289.00
Rate for Payer: MDX Hawaii PPO	$560.66
Rate for Payer: Ohana Health Plan Medicaid	$289.00
Rate for Payer: Ohana Health Plan Medicare	$289.00
Rate for Payer: UnitedHealthcare Medicaid	$25.96
Rate for Payer: UnitedHealthcare Medicare	$289.00
Rate for Payer: University Health Alliance Commercial	$85.69

XR Ribs 3 Views Bilateral - Report

Professional

Both

$120.00

Service Code	HCPCS 71110 26
Hospital Charge Code	630232
Hospital Revenue Code	972
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$102.00
Rate for Payer: AlohaCare Medicaid	$29.19
Rate for Payer: AlohaCare Medicare	$13.72
Rate for Payer: Cash Price	$78.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Devoted Health Medicare	$15.09
Rate for Payer: Hawaii Medical Service Association Medicare	$13.72
Rate for Payer: Hawaii Western Management Group Commercial	$49.76
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$15.09
Rate for Payer: Kaiser Permanente Medicaid	$15.09
Rate for Payer: Kaiser Permanente Medicare	$15.09
Rate for Payer: Ohana Health Plan Medicaid	$29.19
Rate for Payer: Ohana Health Plan Medicare	$13.72
Rate for Payer: UnitedHealthcare Medicaid	$29.19
Rate for Payer: UnitedHealthcare Medicare	$13.72

XR Ribs w/ PA Chest Bilateral

Facility

$667.00

Service Code	HCPCS 71111
Hospital Charge Code	1170377
Hospital Revenue Code	320
Min. Negotiated Rate	$566.95
Max. Negotiated Rate	$646.99
Rate for Payer: Cash Price	$433.55
Rate for Payer: Health Management Network Commercial	$566.95
Rate for Payer: Kaiser Permanente Commercial	$600.30
Rate for Payer: MDX Hawaii PPO	$646.99

XR Ribs w/ PA Chest Bilateral

Facility

$667.00

Service Code	HCPCS 71111
Hospital Charge Code	1170377
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$646.99
Rate for Payer: AlohaCare Medicaid	$333.50
Rate for Payer: AlohaCare Medicare	$333.50
Rate for Payer: Cash Price	$433.55
Rate for Payer: Cash Price	$433.55
Rate for Payer: Devoted Health Medicare	$366.85
Rate for Payer: Hawaii Medical Service Association ABD	$29.64
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$333.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$32.30
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$566.95
Rate for Payer: Humana Medicare	$333.50
Rate for Payer: Kaiser Permanente Commercial	$600.30
Rate for Payer: Kaiser Permanente Medicaid	$340.17
Rate for Payer: Kaiser Permanente Medicare	$333.50
Rate for Payer: MDX Hawaii PPO	$646.99
Rate for Payer: Ohana Health Plan Medicaid	$333.50
Rate for Payer: Ohana Health Plan Medicare	$333.50
Rate for Payer: UnitedHealthcare Medicaid	$29.64
Rate for Payer: UnitedHealthcare Medicare	$333.50
Rate for Payer: University Health Alliance Commercial	$105.84

XR Ribs w/ PA Chest Bilateral - Report

Professional

Both

$145.00

Service Code	HCPCS 71111 26
Hospital Charge Code	630226
Hospital Revenue Code	972
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$34.95
Rate for Payer: AlohaCare Medicare	$15.30
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$16.83
Rate for Payer: Hawaii Medical Service Association Medicare	$15.30
Rate for Payer: Hawaii Western Management Group Commercial	$57.07
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$16.83
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: Kaiser Permanente Medicare	$16.83
Rate for Payer: Ohana Health Plan Medicaid	$34.95
Rate for Payer: Ohana Health Plan Medicare	$15.30
Rate for Payer: UnitedHealthcare Medicaid	$34.95
Rate for Payer: UnitedHealthcare Medicare	$15.30

XR Ribs w/ PA Chest Left

Facility

$525.00

Service Code	HCPCS 71101 LT
Hospital Charge Code	1170379
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$509.25
Rate for Payer: AlohaCare Medicaid	$262.50
Rate for Payer: AlohaCare Medicare	$262.50
Rate for Payer: Cash Price	$341.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Devoted Health Medicare	$288.75
Rate for Payer: Hawaii Medical Service Association ABD	$21.96
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Humana Medicare	$262.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: Kaiser Permanente Medicare	$262.50
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: Ohana Health Plan Medicaid	$262.50
Rate for Payer: Ohana Health Plan Medicare	$262.50
Rate for Payer: UnitedHealthcare Medicaid	$21.96
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$80.36

XR Ribs w/ PA Chest Left

Facility

$525.00

Service Code	HCPCS 71101 LT
Hospital Charge Code	1170379
Hospital Revenue Code	320
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: MDX Hawaii PPO	$509.25

XR Ribs w/ PA Chest Left - Report

Professional

Both

$98.00

Service Code	HCPCS 71101 26,LT
Hospital Charge Code	630224
Hospital Revenue Code	972
Min. Negotiated Rate	$28.11
Max. Negotiated Rate	$83.30
Rate for Payer: AlohaCare Medicaid	$28.11
Rate for Payer: Cash Price	$63.70
Rate for Payer: Cash Price	$63.70
Rate for Payer: Hawaii Western Management Group Commercial	$44.50
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Ohana Health Plan Medicaid	$28.11
Rate for Payer: UnitedHealthcare Medicaid	$28.11

XR Ribs w/ PA Chest Right

Facility

$525.00

Service Code	HCPCS 71101 RT
Hospital Charge Code	1170381
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
Max. Negotiated Rate	$509.25
Rate for Payer: AlohaCare Medicaid	$262.50
Rate for Payer: AlohaCare Medicare	$262.50
Rate for Payer: Cash Price	$341.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Devoted Health Medicare	$288.75
Rate for Payer: Hawaii Medical Service Association ABD	$21.96
Rate for Payer: Hawaii Medical Service Association Medicare	$262.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.13
Rate for Payer: Hawaii Western Management Group Commercial	$498.75
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Humana Medicare	$262.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: Kaiser Permanente Medicare	$262.50
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: Ohana Health Plan Medicaid	$262.50
Rate for Payer: Ohana Health Plan Medicare	$262.50
Rate for Payer: UnitedHealthcare Medicaid	$21.96
Rate for Payer: UnitedHealthcare Medicare	$262.50
Rate for Payer: University Health Alliance Commercial	$80.36

XR Ribs w/ PA Chest Right

Facility

$525.00

Service Code	HCPCS 71101 RT
Hospital Charge Code	1170381
Hospital Revenue Code	320
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: MDX Hawaii PPO	$509.25

XR Ribs w/ PA Chest Right - Report

Professional

Both

$98.00

Service Code	HCPCS 71101 26,RT
Hospital Charge Code	630218
Hospital Revenue Code	972
Min. Negotiated Rate	$28.11
Max. Negotiated Rate	$83.30
Rate for Payer: AlohaCare Medicaid	$28.11
Rate for Payer: Cash Price	$63.70
Rate for Payer: Cash Price	$63.70
Rate for Payer: Hawaii Western Management Group Commercial	$44.50
Rate for Payer: Health Management Network Commercial	$83.30
Rate for Payer: Ohana Health Plan Medicaid	$28.11
Rate for Payer: UnitedHealthcare Medicaid	$28.11

XR Sacroiliac Joints 1 or 2 Views

Facility

$419.00

Service Code	HCPCS 72200
Hospital Charge Code	1170385
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$406.43
Rate for Payer: AlohaCare Medicaid	$209.50
Rate for Payer: AlohaCare Medicare	$209.50
Rate for Payer: Cash Price	$272.35
Rate for Payer: Cash Price	$272.35
Rate for Payer: Devoted Health Medicare	$230.45
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$209.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Humana Medicare	$209.50
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: Kaiser Permanente Medicare	$209.50
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: Ohana Health Plan Medicaid	$209.50
Rate for Payer: Ohana Health Plan Medicare	$209.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$209.50
Rate for Payer: University Health Alliance Commercial	$59.38

XR Sacroiliac Joints 1 or 2 Views

Facility

$419.00

Service Code	HCPCS 72200
Hospital Charge Code	1170385
Hospital Revenue Code	320
Min. Negotiated Rate	$356.15
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$272.35
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: MDX Hawaii PPO	$406.43

Know your out-of-pocket cost for care.

All Charges