Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; L)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381789
Hospital Revenue Code	274
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$209.46
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$81.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association Medicare	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$81.00
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$81.00
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$81.00
Rate for Payer: Ohana Health Plan Medicare	$81.00
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: UnitedHealthcare Medicare	$81.00
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; M)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381788
Hospital Revenue Code	274
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$209.46
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$81.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association Medicare	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$81.00
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$81.00
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$81.00
Rate for Payer: Ohana Health Plan Medicare	$81.00
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: UnitedHealthcare Medicare	$81.00
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; M)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381788
Hospital Revenue Code	274
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; S)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381783
Hospital Revenue Code	274
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; S)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381783
Hospital Revenue Code	274
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$209.46
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$81.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association Medicare	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$81.00
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$81.00
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$81.00
Rate for Payer: Ohana Health Plan Medicare	$81.00
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: UnitedHealthcare Medicare	$81.00
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; XL)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381784
Hospital Revenue Code	274
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$209.46
Rate for Payer: AlohaCare Medicaid	$81.00
Rate for Payer: AlohaCare Medicare	$81.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cash Price	$105.30
Rate for Payer: Devoted Health Medicare	$89.10
Rate for Payer: Hawaii Medical Service Association Medicare	$81.00
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Humana Medicare	$81.00
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: Kaiser Permanente Medicaid	$82.62
Rate for Payer: Kaiser Permanente Medicare	$81.00
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: Ohana Health Plan Medicaid	$81.00
Rate for Payer: Ohana Health Plan Medicare	$81.00
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: UnitedHealthcare Medicare	$81.00
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (thumb spica; XL)

Facility

$162.00

Service Code	HCPCS L3809
Hospital Charge Code	13381784
Hospital Revenue Code	274
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$157.14
Rate for Payer: Cash Price	$105.30
Rate for Payer: Hawaii Western Management Group Commercial	$113.40
Rate for Payer: Health Management Network Commercial	$137.70
Rate for Payer: Kaiser Permanente Commercial	$145.80
Rate for Payer: MDX Hawaii PPO	$157.14
Rate for Payer: University Health Alliance Commercial	$90.72

Wrist hand finger orthosis, w/o joint, prefab, non-customized (wrist widget)

Facility

$209.00

Service Code	HCPCS L3809
Hospital Charge Code	13381785
Hospital Revenue Code	274
Min. Negotiated Rate	$104.50
Max. Negotiated Rate	$209.46
Rate for Payer: AlohaCare Medicaid	$104.50
Rate for Payer: AlohaCare Medicare	$104.50
Rate for Payer: Cash Price	$135.85
Rate for Payer: Cash Price	$135.85
Rate for Payer: Devoted Health Medicare	$114.95
Rate for Payer: Hawaii Medical Service Association Medicare	$104.50
Rate for Payer: Hawaii Western Management Group Commercial	$146.30
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Humana Medicare	$104.50
Rate for Payer: Kaiser Permanente Commercial	$188.10
Rate for Payer: Kaiser Permanente Medicaid	$106.59
Rate for Payer: Kaiser Permanente Medicare	$104.50
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: Ohana Health Plan Medicaid	$104.50
Rate for Payer: Ohana Health Plan Medicare	$104.50
Rate for Payer: UnitedHealthcare Medicaid	$209.46
Rate for Payer: UnitedHealthcare Medicare	$104.50
Rate for Payer: University Health Alliance Commercial	$117.04

Wrist hand finger orthosis, w/o joint, prefab, non-customized (wrist widget)

Facility

$209.00

Service Code	HCPCS L3809
Hospital Charge Code	13381785
Hospital Revenue Code	274
Min. Negotiated Rate	$117.04
Max. Negotiated Rate	$202.73
Rate for Payer: Cash Price	$135.85
Rate for Payer: Hawaii Western Management Group Commercial	$146.30
Rate for Payer: Health Management Network Commercial	$177.65
Rate for Payer: Kaiser Permanente Commercial	$188.10
Rate for Payer: MDX Hawaii PPO	$202.73
Rate for Payer: University Health Alliance Commercial	$117.04

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; L/XL L)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381762
Hospital Revenue Code	274
Min. Negotiated Rate	$77.84
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; L/XL L)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381762
Hospital Revenue Code	274
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; L/XL R)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381764
Hospital Revenue Code	274
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; L/XL R)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381764
Hospital Revenue Code	274
Min. Negotiated Rate	$77.84
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; S/M L)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381766
Hospital Revenue Code	274
Min. Negotiated Rate	$77.84
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; S/M L)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381766
Hospital Revenue Code	274
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; S/M R)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381761
Hospital Revenue Code	274
Min. Negotiated Rate	$77.84
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$90.35
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: University Health Alliance Commercial	$77.84

Wrist hand Orthosis, cock-up, nonmolded, prefab, OTS (green version; S/M R)

Facility

$139.00

Service Code	HCPCS L3908
Hospital Charge Code	13381761
Hospital Revenue Code	274
Min. Negotiated Rate	$49.46
Max. Negotiated Rate	$134.83
Rate for Payer: AlohaCare Medicaid	$69.50
Rate for Payer: AlohaCare Medicare	$69.50
Rate for Payer: Cash Price	$90.35
Rate for Payer: Cash Price	$90.35
Rate for Payer: Devoted Health Medicare	$76.45
Rate for Payer: Hawaii Medical Service Association Medicare	$69.50
Rate for Payer: Hawaii Western Management Group Commercial	$97.30
Rate for Payer: Health Management Network Commercial	$118.15
Rate for Payer: Humana Medicare	$69.50
Rate for Payer: Kaiser Permanente Commercial	$125.10
Rate for Payer: Kaiser Permanente Medicaid	$70.89
Rate for Payer: Kaiser Permanente Medicare	$69.50
Rate for Payer: MDX Hawaii PPO	$134.83
Rate for Payer: Ohana Health Plan Medicaid	$69.50
Rate for Payer: Ohana Health Plan Medicare	$69.50
Rate for Payer: UnitedHealthcare Medicaid	$49.46
Rate for Payer: UnitedHealthcare Medicare	$69.50
Rate for Payer: University Health Alliance Commercial	$77.84

WRIST SPANNING PLATE, TI, 9H

Facility

$3,770.00

Service Code	HCPCS C1713
Hospital Charge Code	13006755
Hospital Revenue Code	278
Min. Negotiated Rate	$1,885.00
Max. Negotiated Rate	$3,656.90
Rate for Payer: AlohaCare Medicaid	$1,885.00
Rate for Payer: AlohaCare Medicare	$1,885.00
Rate for Payer: Cash Price	$2,450.50
Rate for Payer: Devoted Health Medicare	$2,073.50
Rate for Payer: Hawaii Medical Service Association Medicare	$1,885.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,639.00
Rate for Payer: Health Management Network Commercial	$3,204.50
Rate for Payer: Humana Medicare	$1,885.00
Rate for Payer: Kaiser Permanente Commercial	$3,393.00
Rate for Payer: Kaiser Permanente Medicaid	$1,922.70
Rate for Payer: Kaiser Permanente Medicare	$1,885.00
Rate for Payer: MDX Hawaii PPO	$3,656.90
Rate for Payer: Ohana Health Plan Medicaid	$1,885.00
Rate for Payer: Ohana Health Plan Medicare	$1,885.00
Rate for Payer: UnitedHealthcare Medicare	$1,885.00
Rate for Payer: University Health Alliance Commercial	$2,111.20

WRIST SPANNING PLATE, TI, 9H

Facility

$3,770.00

Service Code	HCPCS C1713
Hospital Charge Code	13006755
Hospital Revenue Code	278
Min. Negotiated Rate	$2,111.20
Max. Negotiated Rate	$3,656.90
Rate for Payer: Cash Price	$2,450.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,639.00
Rate for Payer: Health Management Network Commercial	$3,204.50
Rate for Payer: Kaiser Permanente Commercial	$3,393.00
Rate for Payer: MDX Hawaii PPO	$3,656.90
Rate for Payer: University Health Alliance Commercial	$2,111.20

XR Abdomen 1 View

Professional

Both

$161.00

Service Code	HCPCS 74018
Hospital Charge Code	8111091
Hospital Revenue Code	521
Min. Negotiated Rate	$20.11
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$20.11
Rate for Payer: AlohaCare Medicare	$32.60
Rate for Payer: Cash Price	$104.65
Rate for Payer: Cash Price	$104.65
Rate for Payer: Cash Price	$104.65
Rate for Payer: Devoted Health Medicare	$35.86
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$32.81
Rate for Payer: Health Management Network Commercial	$136.85
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$39.12
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Ohana Health Plan Medicaid	$20.11
Rate for Payer: Ohana Health Plan Medicare	$32.60
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

XR Abdomen 1 View

Facility

$367.00

Service Code	HCPCS 74018
Hospital Charge Code	8111091
Hospital Revenue Code	320
Min. Negotiated Rate	$311.95
Max. Negotiated Rate	$355.99
Rate for Payer: Cash Price	$238.55
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: MDX Hawaii PPO	$355.99

XR Abdomen 1 View

Facility

$367.00

Service Code	HCPCS 74018
Hospital Charge Code	8111091
Hospital Revenue Code	320
Min. Negotiated Rate	$18.74
Max. Negotiated Rate	$355.99
Rate for Payer: AlohaCare Medicaid	$183.50
Rate for Payer: AlohaCare Medicare	$183.50
Rate for Payer: Cash Price	$238.55
Rate for Payer: Cash Price	$238.55
Rate for Payer: Devoted Health Medicare	$201.85
Rate for Payer: Hawaii Medical Service Association ABD	$18.74
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$183.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.68
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$311.95
Rate for Payer: Humana Medicare	$183.50
Rate for Payer: Kaiser Permanente Commercial	$330.30
Rate for Payer: Kaiser Permanente Medicaid	$187.17
Rate for Payer: Kaiser Permanente Medicare	$183.50
Rate for Payer: MDX Hawaii PPO	$355.99
Rate for Payer: Ohana Health Plan Medicaid	$183.50
Rate for Payer: Ohana Health Plan Medicare	$183.50
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$183.50
Rate for Payer: University Health Alliance Commercial	$56.31

XR Abdomen 1 View - Report

Professional

Both

$121.00

Service Code	HCPCS 74018 26
Hospital Charge Code	8111093
Hospital Revenue Code	972
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$20.11
Rate for Payer: AlohaCare Medicare	$8.86
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
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	$32.81
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$10.63
Rate for Payer: Kaiser Permanente Medicaid	$10.63
Rate for Payer: Kaiser Permanente Medicare	$10.63
Rate for Payer: Ohana Health Plan Medicaid	$20.11
Rate for Payer: Ohana Health Plan Medicare	$8.86
Rate for Payer: UnitedHealthcare Medicaid	$20.11
Rate for Payer: UnitedHealthcare Medicare	$8.86

XR Abdomen 2 Views

Facility

$385.00

Service Code	HCPCS 74019
Hospital Charge Code	8111094
Hospital Revenue Code	320
Min. Negotiated Rate	$327.25
Max. Negotiated Rate	$373.45
Rate for Payer: Cash Price	$250.25
Rate for Payer: Health Management Network Commercial	$327.25
Rate for Payer: Kaiser Permanente Commercial	$346.50
Rate for Payer: MDX Hawaii PPO	$373.45

XR Abdomen 2 Views

Facility

$385.00

Service Code	HCPCS 74019
Hospital Charge Code	8111094
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$373.45
Rate for Payer: AlohaCare Medicaid	$192.50
Rate for Payer: AlohaCare Medicare	$192.50
Rate for Payer: Cash Price	$250.25
Rate for Payer: Cash Price	$250.25
Rate for Payer: Devoted Health Medicare	$211.75
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$192.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21.30
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$327.25
Rate for Payer: Humana Medicare	$192.50
Rate for Payer: Kaiser Permanente Commercial	$346.50
Rate for Payer: Kaiser Permanente Medicaid	$196.35
Rate for Payer: Kaiser Permanente Medicare	$192.50
Rate for Payer: MDX Hawaii PPO	$373.45
Rate for Payer: Ohana Health Plan Medicaid	$192.50
Rate for Payer: Ohana Health Plan Medicare	$192.50
Rate for Payer: UnitedHealthcare Medicaid	$24.32
Rate for Payer: UnitedHealthcare Medicare	$192.50
Rate for Payer: University Health Alliance Commercial	$68.82

Know your out-of-pocket cost for care.

All Charges