Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG CT HEAD WO CONTR

Facility

$1,763.00

Service Code	HCPCS 70450
Hospital Charge Code	H3510110
Hospital Revenue Code	351
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,710.11
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,145.95
Rate for Payer: Cash Price	$1,145.95
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$139.10
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$169.03
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,498.55
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$1,110.69
Rate for Payer: Kaiser Permanente Medicaid	$899.13
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,710.11
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$139.10
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$465.11

HCHG CT HEAD WO CONTR

Facility

$1,763.00

Service Code	HCPCS 70450
Hospital Charge Code	H3510110
Hospital Revenue Code	351
Min. Negotiated Rate	$1,498.55
Max. Negotiated Rate	$1,710.11
Rate for Payer: Cash Price	$1,145.95
Rate for Payer: Health Management Network Commercial	$1,498.55
Rate for Payer: MDX Hawaii PPO	$1,710.11

HCHG CT HEAD W/WO CONTR

Facility

$2,420.00

Service Code	HCPCS 70470
Hospital Charge Code	H3510106
Hospital Revenue Code	351
Min. Negotiated Rate	$207.21
Max. Negotiated Rate	$2,347.40
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$1,573.00
Rate for Payer: Cash Price	$1,573.00
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$232.90
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$253.12
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$2,057.00
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$1,524.60
Rate for Payer: Kaiser Permanente Medicaid	$1,234.20
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$2,347.40
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$232.90
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$718.67

HCHG CT HEAD W/WO CONTR

Facility

$2,420.00

Service Code	HCPCS 70470
Hospital Charge Code	H3510106
Hospital Revenue Code	351
Min. Negotiated Rate	$2,057.00
Max. Negotiated Rate	$2,347.40
Rate for Payer: Cash Price	$1,573.00
Rate for Payer: Health Management Network Commercial	$2,057.00
Rate for Payer: MDX Hawaii PPO	$2,347.40

HCHG CT HEART W/O DYE; EVAL CORONARY CALCIUM

Facility

$399.00

Service Code	HCPCS 75571
Hospital Charge Code	H3520194
Hospital Revenue Code	352
Min. Negotiated Rate	$31.36
Max. Negotiated Rate	$387.03
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$259.35
Rate for Payer: Cash Price	$259.35
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$31.36
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.09
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$251.37
Rate for Payer: Kaiser Permanente Medicaid	$203.49
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$387.03
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$31.36
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$150.03

HCHG CT HEART W/O DYE; EVAL CORONARY CALCIUM

Facility

$399.00

Service Code	HCPCS 75571
Hospital Charge Code	H3520194
Hospital Revenue Code	352
Min. Negotiated Rate	$339.15
Max. Negotiated Rate	$387.03
Rate for Payer: Cash Price	$259.35
Rate for Payer: Health Management Network Commercial	$339.15
Rate for Payer: MDX Hawaii PPO	$387.03

HCHG CT HEART W WO DYE FUNCT

Facility

$1,508.00

Service Code	HCPCS 75572
Hospital Charge Code	H3500213
Hospital Revenue Code	352
Min. Negotiated Rate	$1,281.80
Max. Negotiated Rate	$1,462.76
Rate for Payer: Cash Price	$980.20
Rate for Payer: Health Management Network Commercial	$1,281.80
Rate for Payer: MDX Hawaii PPO	$1,462.76

HCHG CT HEART W WO DYE FUNCT

Facility

$1,508.00

Service Code	HCPCS 75572
Hospital Charge Code	H3500213
Hospital Revenue Code	352
Min. Negotiated Rate	$97.41
Max. Negotiated Rate	$1,462.76
Rate for Payer: AlohaCare Medicaid	$412.14
Rate for Payer: AlohaCare Medicare	$412.14
Rate for Payer: Cash Price	$980.20
Rate for Payer: Cash Price	$980.20
Rate for Payer: Devoted Health Medicare	$453.35
Rate for Payer: Hawaii Medical Service Association ABD	$97.41
Rate for Payer: Hawaii Medical Service Association Commercial	$515.17
Rate for Payer: Hawaii Medical Service Association Medicare	$412.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$157.44
Rate for Payer: Hawaii Western Management Group Commercial	$412.14
Rate for Payer: Health Management Network Commercial	$1,281.80
Rate for Payer: Humana Medicare	$412.14
Rate for Payer: Kaiser Permanente Commercial	$950.04
Rate for Payer: Kaiser Permanente Medicaid	$769.08
Rate for Payer: Kaiser Permanente Medicare	$412.14
Rate for Payer: MDX Hawaii PPO	$1,462.76
Rate for Payer: Ohana Health Plan Medicaid	$453.35
Rate for Payer: Ohana Health Plan Medicare	$412.14
Rate for Payer: UnitedHealthcare Medicaid	$97.41
Rate for Payer: UnitedHealthcare Medicare	$412.14
Rate for Payer: University Health Alliance Commercial	$544.75

HCHG CT HEEL W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520134
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$1,089.90
Rate for Payer: Kaiser Permanente Medicaid	$882.30
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,678.10
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$497.32

HCHG CT HEEL W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520134
Hospital Revenue Code	352
Min. Negotiated Rate	$1,470.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: MDX Hawaii PPO	$1,678.10

HCHG CT HIP W CONTRAST

Facility

$1,958.00

Service Code	HCPCS 73701
Hospital Charge Code	H3520240
Hospital Revenue Code	352
Min. Negotiated Rate	$194.84
Max. Negotiated Rate	$1,899.26
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$1,233.54
Rate for Payer: Kaiser Permanente Medicaid	$998.58
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$1,899.26
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$662.37

HCHG CT HIP W CONTRAST

Facility

$1,958.00

Service Code	HCPCS 73701
Hospital Charge Code	H3520240
Hospital Revenue Code	352
Min. Negotiated Rate	$1,664.30
Max. Negotiated Rate	$1,899.26
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: MDX Hawaii PPO	$1,899.26

HCHG CT HIP W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520239
Hospital Revenue Code	352
Min. Negotiated Rate	$1,470.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: MDX Hawaii PPO	$1,678.10

HCHG CT HIP W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520239
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$1,089.90
Rate for Payer: Kaiser Permanente Medicaid	$882.30
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,678.10
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$497.32

HCHG CT LEG LOW W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520136
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$1,089.90
Rate for Payer: Kaiser Permanente Medicaid	$882.30
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,678.10
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$497.32

HCHG CT LEG LOW W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520136
Hospital Revenue Code	352
Min. Negotiated Rate	$1,470.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: MDX Hawaii PPO	$1,678.10

HCHG CT LEG UP W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520138
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$1,089.90
Rate for Payer: Kaiser Permanente Medicaid	$882.30
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,678.10
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$497.32

HCHG CT LEG UP W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520138
Hospital Revenue Code	352
Min. Negotiated Rate	$1,470.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: MDX Hawaii PPO	$1,678.10

HCHG CT LMBSC SPINE EXT, WO CONTR

Facility

$1,539.00

Service Code	HCPCS 72131
Hospital Charge Code	H3520140
Hospital Revenue Code	352
Min. Negotiated Rate	$1,308.15
Max. Negotiated Rate	$1,492.83
Rate for Payer: Cash Price	$1,000.35
Rate for Payer: Health Management Network Commercial	$1,308.15
Rate for Payer: MDX Hawaii PPO	$1,492.83

HCHG CT LMBSC SPINE EXT, WO CONTR

Facility

$1,539.00

Service Code	HCPCS 72131
Hospital Charge Code	H3520140
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,492.83
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,000.35
Rate for Payer: Cash Price	$1,000.35
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$177.96
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,308.15
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$969.57
Rate for Payer: Kaiser Permanente Medicaid	$784.89
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,492.83
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$177.96
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$502.27

HCHG CT LOW EXTREM W CONTR

Facility

$1,958.00

Service Code	HCPCS 73701
Hospital Charge Code	H3520130
Hospital Revenue Code	352
Min. Negotiated Rate	$1,664.30
Max. Negotiated Rate	$1,899.26
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: MDX Hawaii PPO	$1,899.26

HCHG CT LOW EXTREM W CONTR

Facility

$1,958.00

Service Code	HCPCS 73701
Hospital Charge Code	H3520130
Hospital Revenue Code	352
Min. Negotiated Rate	$194.84
Max. Negotiated Rate	$1,899.26
Rate for Payer: AlohaCare Medicaid	$207.21
Rate for Payer: AlohaCare Medicare	$207.21
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Cash Price	$1,272.70
Rate for Payer: Devoted Health Medicare	$227.93
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Commercial	$259.01
Rate for Payer: Hawaii Medical Service Association Medicare	$207.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$207.21
Rate for Payer: Health Management Network Commercial	$1,664.30
Rate for Payer: Humana Medicare	$207.21
Rate for Payer: Kaiser Permanente Commercial	$1,233.54
Rate for Payer: Kaiser Permanente Medicaid	$998.58
Rate for Payer: Kaiser Permanente Medicare	$207.21
Rate for Payer: MDX Hawaii PPO	$1,899.26
Rate for Payer: Ohana Health Plan Medicaid	$227.93
Rate for Payer: Ohana Health Plan Medicare	$207.21
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$207.21
Rate for Payer: University Health Alliance Commercial	$662.37

HCHG CT LOW EXTREM W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520128
Hospital Revenue Code	352
Min. Negotiated Rate	$1,470.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: MDX Hawaii PPO	$1,678.10

HCHG CT LOW EXTREM W/O CONTRAST

Facility

$1,730.00

Service Code	HCPCS 73700
Hospital Charge Code	H3520128
Hospital Revenue Code	352
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$1,678.10
Rate for Payer: AlohaCare Medicaid	$123.50
Rate for Payer: AlohaCare Medicare	$123.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Cash Price	$1,124.50
Rate for Payer: Devoted Health Medicare	$135.85
Rate for Payer: Hawaii Medical Service Association ABD	$163.33
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$123.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$177.42
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,470.50
Rate for Payer: Humana Medicare	$123.50
Rate for Payer: Kaiser Permanente Commercial	$1,089.90
Rate for Payer: Kaiser Permanente Medicaid	$882.30
Rate for Payer: Kaiser Permanente Medicare	$123.50
Rate for Payer: MDX Hawaii PPO	$1,678.10
Rate for Payer: Ohana Health Plan Medicaid	$135.85
Rate for Payer: Ohana Health Plan Medicare	$123.50
Rate for Payer: UnitedHealthcare Medicaid	$163.33
Rate for Payer: UnitedHealthcare Medicare	$123.50
Rate for Payer: University Health Alliance Commercial	$497.32

HCHG CT LOW EXTREM W/WO CONTR

Facility

$2,118.00

Service Code	HCPCS 73702
Hospital Charge Code	H3520144
Hospital Revenue Code	352
Min. Negotiated Rate	$1,800.30
Max. Negotiated Rate	$2,054.46
Rate for Payer: Cash Price	$1,376.70
Rate for Payer: Health Management Network Commercial	$1,800.30
Rate for Payer: MDX Hawaii PPO	$2,054.46

Know your out-of-pocket cost for care.

All Charges