Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Small Bowel w/ Multiple Series

Facility

$925.00

Service Code	HCPCS 74250
Hospital Charge Code	1170442
Hospital Revenue Code	320
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$897.25
Rate for Payer: AlohaCare Medicaid	$462.50
Rate for Payer: AlohaCare Medicare	$462.50
Rate for Payer: Cash Price	$601.25
Rate for Payer: Cash Price	$601.25
Rate for Payer: Devoted Health Medicare	$508.75
Rate for Payer: Hawaii Medical Service Association ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$462.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$46.81
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$786.25
Rate for Payer: Humana Medicare	$462.50
Rate for Payer: Kaiser Permanente Commercial	$832.50
Rate for Payer: Kaiser Permanente Medicaid	$471.75
Rate for Payer: Kaiser Permanente Medicare	$462.50
Rate for Payer: MDX Hawaii PPO	$897.25
Rate for Payer: Ohana Health Plan Medicaid	$462.50
Rate for Payer: Ohana Health Plan Medicare	$462.50
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$462.50
Rate for Payer: University Health Alliance Commercial	$191.35

XR Small Bowel w/ Multiple Series - Report

Professional

Both

$185.00

Service Code	HCPCS 74250 26
Hospital Charge Code	630085
Hospital Revenue Code	972
Min. Negotiated Rate	$37.99
Max. Negotiated Rate	$157.25
Rate for Payer: AlohaCare Medicaid	$80.76
Rate for Payer: AlohaCare Medicare	$37.99
Rate for Payer: Cash Price	$120.25
Rate for Payer: Cash Price	$120.25
Rate for Payer: Devoted Health Medicare	$41.79
Rate for Payer: Hawaii Medical Service Association Medicare	$37.99
Rate for Payer: Hawaii Western Management Group Commercial	$82.63
Rate for Payer: Health Management Network Commercial	$157.25
Rate for Payer: Kaiser Permanente Commercial	$41.79
Rate for Payer: Kaiser Permanente Medicaid	$41.79
Rate for Payer: Kaiser Permanente Medicare	$41.79
Rate for Payer: Ohana Health Plan Medicaid	$80.76
Rate for Payer: Ohana Health Plan Medicare	$37.99
Rate for Payer: UnitedHealthcare Medicaid	$80.76
Rate for Payer: UnitedHealthcare Medicare	$37.99

XR Spinal Puncture Diagnostic

Facility

$1,136.00

Service Code	HCPCS 62270
Hospital Charge Code	8127621
Hospital Revenue Code	361
Min. Negotiated Rate	$965.60
Max. Negotiated Rate	$1,101.92
Rate for Payer: Cash Price	$738.40
Rate for Payer: Health Management Network Commercial	$965.60
Rate for Payer: Kaiser Permanente Commercial	$1,022.40
Rate for Payer: MDX Hawaii PPO	$1,101.92

XR Spinal Puncture Diagnostic

Facility

$1,136.00

Service Code	HCPCS 62270
Hospital Charge Code	8127621
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$568.00
Rate for Payer: AlohaCare Medicare	$568.00
Rate for Payer: Cash Price	$738.40
Rate for Payer: Cash Price	$738.40
Rate for Payer: Devoted Health Medicare	$624.80
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	$568.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$965.60
Rate for Payer: Humana Medicare	$568.00
Rate for Payer: Kaiser Permanente Commercial	$1,022.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$568.00
Rate for Payer: MDX Hawaii PPO	$1,101.92
Rate for Payer: Ohana Health Plan Medicaid	$568.00
Rate for Payer: Ohana Health Plan Medicare	$568.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$568.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

XR Spinal Puncture Diagnostic - Report

Professional

Both

$982.00

Service Code	HCPCS 62270
Hospital Charge Code	8127623
Hospital Revenue Code	972
Min. Negotiated Rate	$55.99
Max. Negotiated Rate	$834.70
Rate for Payer: AlohaCare Medicaid	$61.33
Rate for Payer: AlohaCare Medicare	$55.99
Rate for Payer: Cash Price	$638.30
Rate for Payer: Cash Price	$638.30
Rate for Payer: Devoted Health Medicare	$61.59
Rate for Payer: Hawaii Medical Service Association ABD	$61.33
Rate for Payer: Hawaii Medical Service Association Commercial	$113.61
Rate for Payer: Hawaii Medical Service Association Medicare	$55.99
Rate for Payer: Hawaii Medical Service Association Non-ABD	$61.33
Rate for Payer: Hawaii Western Management Group Commercial	$69.68
Rate for Payer: Health Management Network Commercial	$834.70
Rate for Payer: Kaiser Permanente Commercial	$61.59
Rate for Payer: Kaiser Permanente Medicaid	$61.59
Rate for Payer: Kaiser Permanente Medicare	$61.59
Rate for Payer: Ohana Health Plan Medicaid	$61.33
Rate for Payer: Ohana Health Plan Medicare	$55.99
Rate for Payer: UnitedHealthcare Medicaid	$61.33
Rate for Payer: UnitedHealthcare Medicare	$55.99
Rate for Payer: University Health Alliance Commercial	$82.47

XR Spinal Puncture Therapeutic

Facility

$1,136.00

Service Code	HCPCS 62272
Hospital Charge Code	8127624
Hospital Revenue Code	361
Min. Negotiated Rate	$965.60
Max. Negotiated Rate	$1,101.92
Rate for Payer: Cash Price	$738.40
Rate for Payer: Health Management Network Commercial	$965.60
Rate for Payer: Kaiser Permanente Commercial	$1,022.40
Rate for Payer: MDX Hawaii PPO	$1,101.92

XR Spinal Puncture Therapeutic

Facility

$1,136.00

Service Code	HCPCS 62272
Hospital Charge Code	8127624
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$568.00
Rate for Payer: AlohaCare Medicare	$568.00
Rate for Payer: Cash Price	$738.40
Rate for Payer: Cash Price	$738.40
Rate for Payer: Devoted Health Medicare	$624.80
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	$568.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$965.60
Rate for Payer: Humana Medicare	$568.00
Rate for Payer: Kaiser Permanente Commercial	$1,022.40
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$568.00
Rate for Payer: MDX Hawaii PPO	$1,101.92
Rate for Payer: Ohana Health Plan Medicaid	$568.00
Rate for Payer: Ohana Health Plan Medicare	$568.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$568.00
Rate for Payer: University Health Alliance Commercial	$828.03

XR Spinal Puncture Therapeutic - Report

Professional

Both

$982.00

Service Code	HCPCS 62272
Hospital Charge Code	8127626
Hospital Revenue Code	972
Min. Negotiated Rate	$47.58
Max. Negotiated Rate	$834.70
Rate for Payer: AlohaCare Medicaid	$88.34
Rate for Payer: AlohaCare Medicare	$80.65
Rate for Payer: Cash Price	$638.30
Rate for Payer: Cash Price	$638.30
Rate for Payer: Devoted Health Medicare	$88.72
Rate for Payer: Hawaii Medical Service Association ABD	$88.34
Rate for Payer: Hawaii Medical Service Association Commercial	$145.83
Rate for Payer: Hawaii Medical Service Association Medicare	$80.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$88.34
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$834.70
Rate for Payer: Kaiser Permanente Commercial	$88.72
Rate for Payer: Kaiser Permanente Medicaid	$88.72
Rate for Payer: Kaiser Permanente Medicare	$88.72
Rate for Payer: Ohana Health Plan Medicaid	$88.34
Rate for Payer: Ohana Health Plan Medicare	$80.65
Rate for Payer: UnitedHealthcare Medicaid	$88.34
Rate for Payer: UnitedHealthcare Medicare	$80.65
Rate for Payer: University Health Alliance Commercial	$115.85

XR Spine 1 View Specify Level

Facility

$523.00

Service Code	HCPCS 72020
Hospital Charge Code	8102151
Hospital Revenue Code	320
Min. Negotiated Rate	$444.55
Max. Negotiated Rate	$507.31
Rate for Payer: Cash Price	$339.95
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: MDX Hawaii PPO	$507.31

XR Spine 1 View Specify Level

Facility

$523.00

Service Code	HCPCS 72020
Hospital Charge Code	8102151
Hospital Revenue Code	320
Min. Negotiated Rate	$14.98
Max. Negotiated Rate	$507.31
Rate for Payer: AlohaCare Medicaid	$261.50
Rate for Payer: AlohaCare Medicare	$261.50
Rate for Payer: Cash Price	$339.95
Rate for Payer: Cash Price	$339.95
Rate for Payer: Devoted Health Medicare	$287.65
Rate for Payer: Hawaii Medical Service Association ABD	$14.98
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$261.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.73
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$444.55
Rate for Payer: Humana Medicare	$261.50
Rate for Payer: Kaiser Permanente Commercial	$470.70
Rate for Payer: Kaiser Permanente Medicaid	$266.73
Rate for Payer: Kaiser Permanente Medicare	$261.50
Rate for Payer: MDX Hawaii PPO	$507.31
Rate for Payer: Ohana Health Plan Medicaid	$261.50
Rate for Payer: Ohana Health Plan Medicare	$261.50
Rate for Payer: UnitedHealthcare Medicaid	$14.98
Rate for Payer: UnitedHealthcare Medicare	$261.50
Rate for Payer: University Health Alliance Commercial	$48.36

XR Spine 1 View Specify Level - Report

Professional

Both

$121.00

Service Code	HCPCS 72020 26
Hospital Charge Code	8102153
Hospital Revenue Code	972
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$16.04
Rate for Payer: AlohaCare Medicare	$7.82
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$8.60
Rate for Payer: Hawaii Medical Service Association Medicare	$7.82
Rate for Payer: Hawaii Western Management Group Commercial	$26.85
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$8.60
Rate for Payer: Kaiser Permanente Medicaid	$8.60
Rate for Payer: Kaiser Permanente Medicare	$8.60
Rate for Payer: Ohana Health Plan Medicaid	$16.04
Rate for Payer: Ohana Health Plan Medicare	$7.82
Rate for Payer: UnitedHealthcare Medicaid	$16.04
Rate for Payer: UnitedHealthcare Medicare	$7.82

XR Spine Cervical 2 or 3 Views

Facility

$487.00

Service Code	HCPCS 72040
Hospital Charge Code	1170452
Hospital Revenue Code	320
Min. Negotiated Rate	$413.95
Max. Negotiated Rate	$472.39
Rate for Payer: Cash Price	$316.55
Rate for Payer: Health Management Network Commercial	$413.95
Rate for Payer: Kaiser Permanente Commercial	$438.30
Rate for Payer: MDX Hawaii PPO	$472.39

XR Spine Cervical 2 or 3 Views

Facility

$487.00

Service Code	HCPCS 72040
Hospital Charge Code	1170452
Hospital Revenue Code	320
Min. Negotiated Rate	$19.78
Max. Negotiated Rate	$472.39
Rate for Payer: AlohaCare Medicaid	$243.50
Rate for Payer: AlohaCare Medicare	$243.50
Rate for Payer: Cash Price	$316.55
Rate for Payer: Cash Price	$316.55
Rate for Payer: Devoted Health Medicare	$267.85
Rate for Payer: Hawaii Medical Service Association ABD	$19.78
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$243.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.66
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$413.95
Rate for Payer: Humana Medicare	$243.50
Rate for Payer: Kaiser Permanente Commercial	$438.30
Rate for Payer: Kaiser Permanente Medicaid	$248.37
Rate for Payer: Kaiser Permanente Medicare	$243.50
Rate for Payer: MDX Hawaii PPO	$472.39
Rate for Payer: Ohana Health Plan Medicaid	$243.50
Rate for Payer: Ohana Health Plan Medicare	$243.50
Rate for Payer: UnitedHealthcare Medicaid	$19.78
Rate for Payer: UnitedHealthcare Medicare	$243.50
Rate for Payer: University Health Alliance Commercial	$73.65

XR Spine Cervical 2 or 3 Views - Report

Professional

Both

$121.00

Service Code	HCPCS 72040 26
Hospital Charge Code	629601
Hospital Revenue Code	972
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$26.42
Rate for Payer: AlohaCare Medicare	$10.63
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$11.69
Rate for Payer: Hawaii Medical Service Association Medicare	$10.63
Rate for Payer: Hawaii Western Management Group Commercial	$38.42
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$11.69
Rate for Payer: Kaiser Permanente Medicaid	$11.69
Rate for Payer: Kaiser Permanente Medicare	$11.69
Rate for Payer: Ohana Health Plan Medicaid	$26.42
Rate for Payer: Ohana Health Plan Medicare	$10.63
Rate for Payer: UnitedHealthcare Medicaid	$26.42
Rate for Payer: UnitedHealthcare Medicare	$10.63

XR Spine Cervical 4 or 5 Views

Facility

$591.00

Service Code	HCPCS 72050
Hospital Charge Code	1170454
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$573.27
Rate for Payer: AlohaCare Medicaid	$295.50
Rate for Payer: AlohaCare Medicare	$295.50
Rate for Payer: Cash Price	$384.15
Rate for Payer: Cash Price	$384.15
Rate for Payer: Devoted Health Medicare	$325.05
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	$295.50
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	$502.35
Rate for Payer: Humana Medicare	$295.50
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: Kaiser Permanente Medicaid	$301.41
Rate for Payer: Kaiser Permanente Medicare	$295.50
Rate for Payer: MDX Hawaii PPO	$573.27
Rate for Payer: Ohana Health Plan Medicaid	$295.50
Rate for Payer: Ohana Health Plan Medicare	$295.50
Rate for Payer: UnitedHealthcare Medicaid	$29.64
Rate for Payer: UnitedHealthcare Medicare	$295.50
Rate for Payer: University Health Alliance Commercial	$105.14

XR Spine Cervical 4 or 5 Views

Facility

$591.00

Service Code	HCPCS 72050
Hospital Charge Code	1170454
Hospital Revenue Code	320
Min. Negotiated Rate	$502.35
Max. Negotiated Rate	$573.27
Rate for Payer: Cash Price	$384.15
Rate for Payer: Health Management Network Commercial	$502.35
Rate for Payer: Kaiser Permanente Commercial	$531.90
Rate for Payer: MDX Hawaii PPO	$573.27

XR Spine Cervical 4 or 5 Views - Report

Professional

Both

$100.00

Service Code	HCPCS 72050 26
Hospital Charge Code	629603
Hospital Revenue Code	972
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$85.00
Rate for Payer: AlohaCare Medicaid	$35.91
Rate for Payer: AlohaCare Medicare	$13.25
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Devoted Health Medicare	$14.57
Rate for Payer: Hawaii Medical Service Association Medicare	$13.25
Rate for Payer: Hawaii Western Management Group Commercial	$56.40
Rate for Payer: Health Management Network Commercial	$85.00
Rate for Payer: Kaiser Permanente Commercial	$14.57
Rate for Payer: Kaiser Permanente Medicaid	$14.57
Rate for Payer: Kaiser Permanente Medicare	$14.57
Rate for Payer: Ohana Health Plan Medicaid	$35.91
Rate for Payer: Ohana Health Plan Medicare	$13.25
Rate for Payer: UnitedHealthcare Medicaid	$35.91
Rate for Payer: UnitedHealthcare Medicare	$13.25

XR Spine Cervical 6+ Views

Facility

$744.00

Service Code	HCPCS 72052
Hospital Charge Code	1170461
Hospital Revenue Code	320
Min. Negotiated Rate	$39.85
Max. Negotiated Rate	$721.68
Rate for Payer: AlohaCare Medicaid	$372.00
Rate for Payer: AlohaCare Medicare	$372.00
Rate for Payer: Cash Price	$483.60
Rate for Payer: Cash Price	$483.60
Rate for Payer: Devoted Health Medicare	$409.20
Rate for Payer: Hawaii Medical Service Association ABD	$39.85
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$372.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.84
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$632.40
Rate for Payer: Humana Medicare	$372.00
Rate for Payer: Kaiser Permanente Commercial	$669.60
Rate for Payer: Kaiser Permanente Medicaid	$379.44
Rate for Payer: Kaiser Permanente Medicare	$372.00
Rate for Payer: MDX Hawaii PPO	$721.68
Rate for Payer: Ohana Health Plan Medicaid	$372.00
Rate for Payer: Ohana Health Plan Medicare	$372.00
Rate for Payer: UnitedHealthcare Medicaid	$39.85
Rate for Payer: UnitedHealthcare Medicare	$372.00
Rate for Payer: University Health Alliance Commercial	$132.40

XR Spine Cervical 6+ Views

Facility

$744.00

Service Code	HCPCS 72052
Hospital Charge Code	1170461
Hospital Revenue Code	320
Min. Negotiated Rate	$632.40
Max. Negotiated Rate	$721.68
Rate for Payer: Cash Price	$483.60
Rate for Payer: Health Management Network Commercial	$632.40
Rate for Payer: Kaiser Permanente Commercial	$669.60
Rate for Payer: MDX Hawaii PPO	$721.68

XR Spine Cervical 6+ Views - Report

Professional

Both

$145.00

Service Code	HCPCS 72052 26
Hospital Charge Code	629613
Hospital Revenue Code	972
Min. Negotiated Rate	$14.63
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$41.90
Rate for Payer: AlohaCare Medicare	$14.63
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$16.09
Rate for Payer: Hawaii Medical Service Association Medicare	$14.63
Rate for Payer: Hawaii Western Management Group Commercial	$69.44
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$16.09
Rate for Payer: Kaiser Permanente Medicaid	$16.09
Rate for Payer: Kaiser Permanente Medicare	$16.09
Rate for Payer: Ohana Health Plan Medicaid	$41.90
Rate for Payer: Ohana Health Plan Medicare	$14.63
Rate for Payer: UnitedHealthcare Medicaid	$41.90
Rate for Payer: UnitedHealthcare Medicare	$14.63

XR Spine Lumbosacral 2 or 3 Views

Facility

$578.00

Service Code	HCPCS 72100
Hospital Charge Code	1170470
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 Spine Lumbosacral 2 or 3 Views

Facility

$578.00

Service Code	HCPCS 72100
Hospital Charge Code	1170470
Hospital Revenue Code	320
Min. Negotiated Rate	$21.96
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	$21.96
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	$24.13
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	$21.96
Rate for Payer: UnitedHealthcare Medicare	$289.00
Rate for Payer: University Health Alliance Commercial	$77.64

XR Spine Lumbosacral 2 or 3 Views - Report

Professional

Both

$76.00

Service Code	HCPCS 72100 26
Hospital Charge Code	630050
Hospital Revenue Code	972
Min. Negotiated Rate	$11.01
Max. Negotiated Rate	$64.60
Rate for Payer: AlohaCare Medicaid	$26.65
Rate for Payer: AlohaCare Medicare	$11.01
Rate for Payer: Cash Price	$49.40
Rate for Payer: Cash Price	$49.40
Rate for Payer: Devoted Health Medicare	$12.11
Rate for Payer: Hawaii Medical Service Association Medicare	$11.01
Rate for Payer: Hawaii Western Management Group Commercial	$41.42
Rate for Payer: Health Management Network Commercial	$64.60
Rate for Payer: Kaiser Permanente Commercial	$12.11
Rate for Payer: Kaiser Permanente Medicaid	$12.11
Rate for Payer: Kaiser Permanente Medicare	$12.11
Rate for Payer: Ohana Health Plan Medicaid	$26.65
Rate for Payer: Ohana Health Plan Medicare	$11.01
Rate for Payer: UnitedHealthcare Medicaid	$26.65
Rate for Payer: UnitedHealthcare Medicare	$11.01

XR Spine Lumbosacral 4plus Views

Facility

$758.00

Service Code	HCPCS 72110
Hospital Charge Code	1170476
Hospital Revenue Code	320
Min. Negotiated Rate	$32.35
Max. Negotiated Rate	$735.26
Rate for Payer: AlohaCare Medicaid	$379.00
Rate for Payer: AlohaCare Medicare	$379.00
Rate for Payer: Cash Price	$492.70
Rate for Payer: Cash Price	$492.70
Rate for Payer: Devoted Health Medicare	$416.90
Rate for Payer: Hawaii Medical Service Association ABD	$32.35
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$379.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.97
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Humana Medicare	$379.00
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: Kaiser Permanente Medicaid	$386.58
Rate for Payer: Kaiser Permanente Medicare	$379.00
Rate for Payer: MDX Hawaii PPO	$735.26
Rate for Payer: Ohana Health Plan Medicaid	$379.00
Rate for Payer: Ohana Health Plan Medicare	$379.00
Rate for Payer: UnitedHealthcare Medicaid	$32.35
Rate for Payer: UnitedHealthcare Medicare	$379.00
Rate for Payer: University Health Alliance Commercial	$108.35

XR Spine Lumbosacral 4plus Views

Facility

$758.00

Service Code	HCPCS 72110
Hospital Charge Code	1170476
Hospital Revenue Code	320
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

Know your out-of-pocket cost for care.

All Charges