Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Spine Lumbosacral 4plus Views - Report

Professional

Both

$145.00

Service Code	HCPCS 72110 26
Hospital Charge Code	630023
Hospital Revenue Code	972
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$34.79
Rate for Payer: AlohaCare Medicare	$12.91
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$14.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.91
Rate for Payer: Hawaii Western Management Group Commercial	$57.23
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$14.20
Rate for Payer: Kaiser Permanente Medicaid	$14.20
Rate for Payer: Kaiser Permanente Medicare	$14.20
Rate for Payer: Ohana Health Plan Medicaid	$34.79
Rate for Payer: Ohana Health Plan Medicare	$12.91
Rate for Payer: UnitedHealthcare Medicaid	$34.79
Rate for Payer: UnitedHealthcare Medicare	$12.91

XR Spine Lumbosacral Bending 2-3 Views

Facility

$708.00

Service Code	HCPCS 72120
Hospital Charge Code	1170472
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
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	$354.00
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	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$29.64
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$97.90

XR Spine Lumbosacral Bending 2-3 Views

Facility

$708.00

Service Code	HCPCS 72120
Hospital Charge Code	1170472
Hospital Revenue Code	320
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

XR Spine Lumbosacral Bending 2-3 Views - Report

Professional

Both

$76.00

Service Code	HCPCS 72120 26
Hospital Charge Code	630033
Hospital Revenue Code	972
Min. Negotiated Rate	$11.01
Max. Negotiated Rate	$64.60
Rate for Payer: AlohaCare Medicaid	$27.11
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	$51.52
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	$27.11
Rate for Payer: Ohana Health Plan Medicare	$11.01
Rate for Payer: UnitedHealthcare Medicaid	$27.11
Rate for Payer: UnitedHealthcare Medicare	$11.01

XR Spine Lumbosacral w/ Bending 6+ Views

Facility

$708.00

Service Code	HCPCS 72114
Hospital Charge Code	1170474
Hospital Revenue Code	320
Min. Negotiated Rate	$39.30
Max. Negotiated Rate	$686.76
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$354.00
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Devoted Health Medicare	$389.40
Rate for Payer: Hawaii Medical Service Association ABD	$39.30
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$354.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$42.37
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$354.00
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$361.08
Rate for Payer: Kaiser Permanente Medicare	$354.00
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$354.00
Rate for Payer: Ohana Health Plan Medicare	$354.00
Rate for Payer: UnitedHealthcare Medicaid	$39.30
Rate for Payer: UnitedHealthcare Medicare	$354.00
Rate for Payer: University Health Alliance Commercial	$141.23

XR Spine Lumbosacral w/ Bending 6+ Views

Facility

$708.00

Service Code	HCPCS 72114
Hospital Charge Code	1170474
Hospital Revenue Code	320
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

XR Spine Lumbosacral w/ Bending 6+ Views - Report

Professional

Both

$145.00

Service Code	HCPCS 72114 26
Hospital Charge Code	630029
Hospital Revenue Code	972
Min. Negotiated Rate	$14.63
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$40.98
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	$71.81
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	$40.98
Rate for Payer: Ohana Health Plan Medicare	$14.63
Rate for Payer: UnitedHealthcare Medicaid	$40.98
Rate for Payer: UnitedHealthcare Medicare	$14.63

XR Spine Scoliosis 1 View

Facility

$461.00

Service Code	HCPCS 72081
Hospital Charge Code	7520627
Hospital Revenue Code	320
Min. Negotiated Rate	$17.62
Max. Negotiated Rate	$447.17
Rate for Payer: AlohaCare Medicaid	$230.50
Rate for Payer: AlohaCare Medicare	$230.50
Rate for Payer: Cash Price	$299.65
Rate for Payer: Cash Price	$299.65
Rate for Payer: Devoted Health Medicare	$253.55
Rate for Payer: Hawaii Medical Service Association ABD	$17.62
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$230.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$24.05
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Humana Medicare	$230.50
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: Kaiser Permanente Medicaid	$235.11
Rate for Payer: Kaiser Permanente Medicare	$230.50
Rate for Payer: MDX Hawaii PPO	$447.17
Rate for Payer: Ohana Health Plan Medicaid	$230.50
Rate for Payer: Ohana Health Plan Medicare	$230.50
Rate for Payer: UnitedHealthcare Medicaid	$28.37
Rate for Payer: UnitedHealthcare Medicare	$230.50
Rate for Payer: University Health Alliance Commercial	$80.07

XR Spine Scoliosis 1 View

Facility

$461.00

Service Code	HCPCS 72081
Hospital Charge Code	7520627
Hospital Revenue Code	320
Min. Negotiated Rate	$391.85
Max. Negotiated Rate	$447.17
Rate for Payer: Cash Price	$299.65
Rate for Payer: Health Management Network Commercial	$391.85
Rate for Payer: Kaiser Permanente Commercial	$414.90
Rate for Payer: MDX Hawaii PPO	$447.17

XR Spine Scoliosis 1 View - Report

Professional

Both

$121.00

Service Code	HCPCS 72081 26
Hospital Charge Code	7520629
Hospital Revenue Code	972
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$28.37
Rate for Payer: AlohaCare Medicare	$12.91
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$14.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.91
Rate for Payer: Hawaii Western Management Group Commercial	$43.28
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$14.20
Rate for Payer: Kaiser Permanente Medicaid	$14.20
Rate for Payer: Kaiser Permanente Medicare	$14.20
Rate for Payer: Ohana Health Plan Medicaid	$28.37
Rate for Payer: Ohana Health Plan Medicare	$12.91
Rate for Payer: UnitedHealthcare Medicaid	$28.37
Rate for Payer: UnitedHealthcare Medicare	$12.91

XR Spine Scoliosis 2-3 Views

Facility

$545.00

Service Code	HCPCS 72082
Hospital Charge Code	7520630
Hospital Revenue Code	320
Min. Negotiated Rate	$32.11
Max. Negotiated Rate	$528.65
Rate for Payer: AlohaCare Medicaid	$272.50
Rate for Payer: AlohaCare Medicare	$272.50
Rate for Payer: Cash Price	$354.25
Rate for Payer: Cash Price	$354.25
Rate for Payer: Devoted Health Medicare	$299.75
Rate for Payer: Hawaii Medical Service Association ABD	$32.11
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$272.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$43.87
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$463.25
Rate for Payer: Humana Medicare	$272.50
Rate for Payer: Kaiser Permanente Commercial	$490.50
Rate for Payer: Kaiser Permanente Medicaid	$277.95
Rate for Payer: Kaiser Permanente Medicare	$272.50
Rate for Payer: MDX Hawaii PPO	$528.65
Rate for Payer: Ohana Health Plan Medicaid	$272.50
Rate for Payer: Ohana Health Plan Medicare	$272.50
Rate for Payer: UnitedHealthcare Medicaid	$47.15
Rate for Payer: UnitedHealthcare Medicare	$272.50
Rate for Payer: University Health Alliance Commercial	$130.35

XR Spine Scoliosis 2-3 Views

Facility

$545.00

Service Code	HCPCS 72082
Hospital Charge Code	7520630
Hospital Revenue Code	320
Min. Negotiated Rate	$463.25
Max. Negotiated Rate	$528.65
Rate for Payer: Cash Price	$354.25
Rate for Payer: Health Management Network Commercial	$463.25
Rate for Payer: Kaiser Permanente Commercial	$490.50
Rate for Payer: MDX Hawaii PPO	$528.65

XR Spine Scoliosis 2-3 Views - Report

Professional

Both

$145.00

Service Code	HCPCS 72082 26
Hospital Charge Code	7520632
Hospital Revenue Code	972
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$47.15
Rate for Payer: AlohaCare Medicare	$15.34
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$16.87
Rate for Payer: Hawaii Medical Service Association Medicare	$15.34
Rate for Payer: Hawaii Western Management Group Commercial	$70.46
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$16.87
Rate for Payer: Kaiser Permanente Medicaid	$16.87
Rate for Payer: Kaiser Permanente Medicare	$16.87
Rate for Payer: Ohana Health Plan Medicaid	$47.15
Rate for Payer: Ohana Health Plan Medicare	$15.34
Rate for Payer: UnitedHealthcare Medicaid	$47.15
Rate for Payer: UnitedHealthcare Medicare	$15.34

XR Spine Scoliosis 4-5 Views

Facility

$592.00

Service Code	HCPCS 72083
Hospital Charge Code	7520624
Hospital Revenue Code	320
Min. Negotiated Rate	$503.20
Max. Negotiated Rate	$574.24
Rate for Payer: Cash Price	$384.80
Rate for Payer: Health Management Network Commercial	$503.20
Rate for Payer: Kaiser Permanente Commercial	$532.80
Rate for Payer: MDX Hawaii PPO	$574.24

XR Spine Scoliosis 4-5 Views

Facility

$592.00

Service Code	HCPCS 72083
Hospital Charge Code	7520624
Hospital Revenue Code	320
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$574.24
Rate for Payer: AlohaCare Medicaid	$296.00
Rate for Payer: AlohaCare Medicare	$296.00
Rate for Payer: Cash Price	$384.80
Rate for Payer: Cash Price	$384.80
Rate for Payer: Devoted Health Medicare	$325.60
Rate for Payer: Hawaii Medical Service Association ABD	$34.85
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$296.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$47.60
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$503.20
Rate for Payer: Humana Medicare	$296.00
Rate for Payer: Kaiser Permanente Commercial	$532.80
Rate for Payer: Kaiser Permanente Medicaid	$301.92
Rate for Payer: Kaiser Permanente Medicare	$296.00
Rate for Payer: MDX Hawaii PPO	$574.24
Rate for Payer: Ohana Health Plan Medicaid	$296.00
Rate for Payer: Ohana Health Plan Medicare	$296.00
Rate for Payer: UnitedHealthcare Medicaid	$53.34
Rate for Payer: UnitedHealthcare Medicare	$296.00
Rate for Payer: University Health Alliance Commercial	$166.83

XR Spine Scoliosis 4-5 Views - Report

Professional

Both

$145.00

Service Code	HCPCS 72083 26
Hospital Charge Code	7520626
Hospital Revenue Code	972
Min. Negotiated Rate	$17.44
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$53.34
Rate for Payer: AlohaCare Medicare	$17.44
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$19.18
Rate for Payer: Hawaii Medical Service Association Medicare	$17.44
Rate for Payer: Hawaii Western Management Group Commercial	$76.48
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$19.18
Rate for Payer: Kaiser Permanente Medicaid	$19.18
Rate for Payer: Kaiser Permanente Medicare	$19.18
Rate for Payer: Ohana Health Plan Medicaid	$53.34
Rate for Payer: Ohana Health Plan Medicare	$17.44
Rate for Payer: UnitedHealthcare Medicaid	$53.34
Rate for Payer: UnitedHealthcare Medicare	$17.44

XR Spine Scoliosis 6+ Views

Facility

$773.00

Service Code	HCPCS 72084
Hospital Charge Code	7520633
Hospital Revenue Code	320
Min. Negotiated Rate	$657.05
Max. Negotiated Rate	$749.81
Rate for Payer: Cash Price	$502.45
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Kaiser Permanente Commercial	$695.70
Rate for Payer: MDX Hawaii PPO	$749.81

XR Spine Scoliosis 6+ Views

Facility

$773.00

Service Code	HCPCS 72084
Hospital Charge Code	7520633
Hospital Revenue Code	320
Min. Negotiated Rate	$41.85
Max. Negotiated Rate	$749.81
Rate for Payer: AlohaCare Medicaid	$386.50
Rate for Payer: AlohaCare Medicare	$386.50
Rate for Payer: Cash Price	$502.45
Rate for Payer: Cash Price	$502.45
Rate for Payer: Devoted Health Medicare	$425.15
Rate for Payer: Hawaii Medical Service Association ABD	$41.85
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$386.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$57.17
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$657.05
Rate for Payer: Humana Medicare	$386.50
Rate for Payer: Kaiser Permanente Commercial	$695.70
Rate for Payer: Kaiser Permanente Medicaid	$394.23
Rate for Payer: Kaiser Permanente Medicare	$386.50
Rate for Payer: MDX Hawaii PPO	$749.81
Rate for Payer: Ohana Health Plan Medicaid	$386.50
Rate for Payer: Ohana Health Plan Medicare	$386.50
Rate for Payer: UnitedHealthcare Medicaid	$66.24
Rate for Payer: UnitedHealthcare Medicare	$386.50
Rate for Payer: University Health Alliance Commercial	$205.85

XR Spine Thoracic 2 Views

Facility

$515.00

Service Code	HCPCS 72070
Hospital Charge Code	1170484
Hospital Revenue Code	320
Min. Negotiated Rate	$437.75
Max. Negotiated Rate	$499.55
Rate for Payer: Cash Price	$334.75
Rate for Payer: Health Management Network Commercial	$437.75
Rate for Payer: Kaiser Permanente Commercial	$463.50
Rate for Payer: MDX Hawaii PPO	$499.55

XR Spine Thoracic 2 Views

Facility

$515.00

Service Code	HCPCS 72070
Hospital Charge Code	1170484
Hospital Revenue Code	320
Min. Negotiated Rate	$21.34
Max. Negotiated Rate	$499.55
Rate for Payer: AlohaCare Medicaid	$257.50
Rate for Payer: AlohaCare Medicare	$257.50
Rate for Payer: Cash Price	$334.75
Rate for Payer: Cash Price	$334.75
Rate for Payer: Devoted Health Medicare	$283.25
Rate for Payer: Hawaii Medical Service Association ABD	$21.34
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$257.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$23.43
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$437.75
Rate for Payer: Humana Medicare	$257.50
Rate for Payer: Kaiser Permanente Commercial	$463.50
Rate for Payer: Kaiser Permanente Medicaid	$262.65
Rate for Payer: Kaiser Permanente Medicare	$257.50
Rate for Payer: MDX Hawaii PPO	$499.55
Rate for Payer: Ohana Health Plan Medicaid	$257.50
Rate for Payer: Ohana Health Plan Medicare	$257.50
Rate for Payer: UnitedHealthcare Medicaid	$21.34
Rate for Payer: UnitedHealthcare Medicare	$257.50
Rate for Payer: University Health Alliance Commercial	$70.43

XR Spine Thoracic 2 Views - Report

Professional

Both

$85.00

Service Code	HCPCS 72070 26
Hospital Charge Code	630003
Hospital Revenue Code	972
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$72.25
Rate for Payer: AlohaCare Medicaid	$21.89
Rate for Payer: AlohaCare Medicare	$9.91
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$10.90
Rate for Payer: Hawaii Medical Service Association Medicare	$9.91
Rate for Payer: Hawaii Western Management Group Commercial	$40.59
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$10.90
Rate for Payer: Kaiser Permanente Medicaid	$10.90
Rate for Payer: Kaiser Permanente Medicare	$10.90
Rate for Payer: Ohana Health Plan Medicaid	$21.89
Rate for Payer: Ohana Health Plan Medicare	$9.91
Rate for Payer: UnitedHealthcare Medicaid	$21.89
Rate for Payer: UnitedHealthcare Medicare	$9.91

XR Spine Thoracic 3 Views

Facility

$553.00

Service Code	HCPCS 72072
Hospital Charge Code	1170486
Hospital Revenue Code	320
Min. Negotiated Rate	$470.05
Max. Negotiated Rate	$536.41
Rate for Payer: Cash Price	$359.45
Rate for Payer: Health Management Network Commercial	$470.05
Rate for Payer: Kaiser Permanente Commercial	$497.70
Rate for Payer: MDX Hawaii PPO	$536.41

XR Spine Thoracic 3 Views

Facility

$553.00

Service Code	HCPCS 72072
Hospital Charge Code	1170486
Hospital Revenue Code	320
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$536.41
Rate for Payer: AlohaCare Medicaid	$276.50
Rate for Payer: AlohaCare Medicare	$276.50
Rate for Payer: Cash Price	$359.45
Rate for Payer: Cash Price	$359.45
Rate for Payer: Devoted Health Medicare	$304.15
Rate for Payer: Hawaii Medical Service Association ABD	$24.39
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$276.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26.81
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$470.05
Rate for Payer: Humana Medicare	$276.50
Rate for Payer: Kaiser Permanente Commercial	$497.70
Rate for Payer: Kaiser Permanente Medicaid	$282.03
Rate for Payer: Kaiser Permanente Medicare	$276.50
Rate for Payer: MDX Hawaii PPO	$536.41
Rate for Payer: Ohana Health Plan Medicaid	$276.50
Rate for Payer: Ohana Health Plan Medicare	$276.50
Rate for Payer: UnitedHealthcare Medicaid	$24.39
Rate for Payer: UnitedHealthcare Medicare	$276.50
Rate for Payer: University Health Alliance Commercial	$78.96

XR Spine Thoracic 3 Views - Report

Professional

Both

$85.00

Service Code	HCPCS 72072 26
Hospital Charge Code	629999
Hospital Revenue Code	972
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$72.25
Rate for Payer: AlohaCare Medicaid	$26.39
Rate for Payer: AlohaCare Medicare	$10.58
Rate for Payer: Cash Price	$55.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Devoted Health Medicare	$11.64
Rate for Payer: Hawaii Medical Service Association Medicare	$10.58
Rate for Payer: Hawaii Western Management Group Commercial	$44.41
Rate for Payer: Health Management Network Commercial	$72.25
Rate for Payer: Kaiser Permanente Commercial	$11.64
Rate for Payer: Kaiser Permanente Medicaid	$11.64
Rate for Payer: Kaiser Permanente Medicare	$11.64
Rate for Payer: Ohana Health Plan Medicaid	$26.39
Rate for Payer: Ohana Health Plan Medicare	$10.58
Rate for Payer: UnitedHealthcare Medicaid	$26.39
Rate for Payer: UnitedHealthcare Medicare	$10.58

XR Spine Thoracic 4+ Views

Facility

$548.00

Service Code	HCPCS 72074
Hospital Charge Code	1170488
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

Know your out-of-pocket cost for care.

All Charges