Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Chest 4+ Views

Facility

$606.00

Service Code	HCPCS 71048
Hospital Charge Code	1170053
Hospital Revenue Code	324
Min. Negotiated Rate	$25.96
Max. Negotiated Rate	$587.82
Rate for Payer: AlohaCare Medicaid	$303.00
Rate for Payer: AlohaCare Medicare	$303.00
Rate for Payer: Cash Price	$393.90
Rate for Payer: Cash Price	$393.90
Rate for Payer: Devoted Health Medicare	$333.30
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	$303.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29.09
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$515.10
Rate for Payer: Humana Medicare	$303.00
Rate for Payer: Kaiser Permanente Commercial	$545.40
Rate for Payer: Kaiser Permanente Medicaid	$309.06
Rate for Payer: Kaiser Permanente Medicare	$303.00
Rate for Payer: MDX Hawaii PPO	$587.82
Rate for Payer: Ohana Health Plan Medicaid	$303.00
Rate for Payer: Ohana Health Plan Medicare	$303.00
Rate for Payer: UnitedHealthcare Medicaid	$30.28
Rate for Payer: UnitedHealthcare Medicare	$303.00
Rate for Payer: University Health Alliance Commercial	$86.36

XR Chest 4+ Views

Facility

$606.00

Service Code	HCPCS 71048
Hospital Charge Code	1170053
Hospital Revenue Code	324
Min. Negotiated Rate	$515.10
Max. Negotiated Rate	$587.82
Rate for Payer: Cash Price	$393.90
Rate for Payer: Health Management Network Commercial	$515.10
Rate for Payer: Kaiser Permanente Commercial	$545.40
Rate for Payer: MDX Hawaii PPO	$587.82

XR Chest 4+ Views - Report

Professional

Both

$145.00

Service Code	HCPCS 71048 26
Hospital Charge Code	629727
Hospital Revenue Code	972
Min. Negotiated Rate	$14.96
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$30.28
Rate for Payer: AlohaCare Medicare	$14.96
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$16.46
Rate for Payer: Hawaii Medical Service Association Medicare	$14.96
Rate for Payer: Hawaii Western Management Group Commercial	$51.55
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$17.95
Rate for Payer: Kaiser Permanente Medicaid	$17.95
Rate for Payer: Kaiser Permanente Medicare	$17.95
Rate for Payer: Ohana Health Plan Medicaid	$30.28
Rate for Payer: Ohana Health Plan Medicare	$14.96
Rate for Payer: UnitedHealthcare Medicaid	$30.28
Rate for Payer: UnitedHealthcare Medicare	$14.96

XR Cholangiogram Injection Procedure

Facility

$8,004.00

Service Code	HCPCS 47531
Hospital Charge Code	2425440
Hospital Revenue Code	361
Min. Negotiated Rate	$6,803.40
Max. Negotiated Rate	$7,763.88
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Health Management Network Commercial	$6,803.40
Rate for Payer: Kaiser Permanente Commercial	$7,203.60
Rate for Payer: MDX Hawaii PPO	$7,763.88

XR Cholangiogram Injection Procedure

Facility

$8,004.00

Service Code	HCPCS 47531
Hospital Charge Code	2425440
Hospital Revenue Code	361
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,763.88
Rate for Payer: AlohaCare Medicaid	$4,002.00
Rate for Payer: AlohaCare Medicare	$4,002.00
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Cash Price	$5,202.60
Rate for Payer: Devoted Health Medicare	$4,402.20
Rate for Payer: Hawaii Medical Service Association Commercial	$4,572.44
Rate for Payer: Hawaii Medical Service Association Medicare	$4,002.00
Rate for Payer: Health Management Network Commercial	$6,803.40
Rate for Payer: Humana Medicare	$4,002.00
Rate for Payer: Kaiser Permanente Commercial	$7,203.60
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,002.00
Rate for Payer: MDX Hawaii PPO	$7,763.88
Rate for Payer: Ohana Health Plan Medicaid	$4,002.00
Rate for Payer: Ohana Health Plan Medicare	$4,002.00
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,002.00
Rate for Payer: University Health Alliance Commercial	$4,482.24

XR Cholangiogram Injection Procedure - Report

Professional

Both

$4,983.00

Service Code	HCPCS 47531
Hospital Charge Code	2425442
Hospital Revenue Code	972
Min. Negotiated Rate	$61.84
Max. Negotiated Rate	$4,235.55
Rate for Payer: AlohaCare Medicaid	$69.80
Rate for Payer: AlohaCare Medicare	$61.84
Rate for Payer: Cash Price	$3,238.95
Rate for Payer: Cash Price	$3,238.95
Rate for Payer: Devoted Health Medicare	$68.02
Rate for Payer: Hawaii Medical Service Association ABD	$69.80
Rate for Payer: Hawaii Medical Service Association Commercial	$142.05
Rate for Payer: Hawaii Medical Service Association Medicare	$61.84
Rate for Payer: Hawaii Medical Service Association Non-ABD	$69.80
Rate for Payer: Hawaii Western Management Group Commercial	$426.92
Rate for Payer: Health Management Network Commercial	$4,235.55
Rate for Payer: Kaiser Permanente Commercial	$74.21
Rate for Payer: Kaiser Permanente Medicaid	$74.21
Rate for Payer: Kaiser Permanente Medicare	$74.21
Rate for Payer: Ohana Health Plan Medicaid	$69.80
Rate for Payer: Ohana Health Plan Medicare	$61.84
Rate for Payer: UnitedHealthcare Medicaid	$69.80
Rate for Payer: UnitedHealthcare Medicare	$61.84
Rate for Payer: University Health Alliance Commercial	$87.08

XR Cholangiogram in OR

Facility

$617.00

Service Code	HCPCS 74300
Hospital Charge Code	1170065
Hospital Revenue Code	320
Min. Negotiated Rate	$524.45
Max. Negotiated Rate	$598.49
Rate for Payer: Cash Price	$401.05
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: MDX Hawaii PPO	$598.49

XR Cholangiogram in OR

Facility

$617.00

Service Code	HCPCS 74300
Hospital Charge Code	1170065
Hospital Revenue Code	320
Min. Negotiated Rate	$18.78
Max. Negotiated Rate	$598.49
Rate for Payer: AlohaCare Medicaid	$308.50
Rate for Payer: AlohaCare Medicare	$308.50
Rate for Payer: Cash Price	$401.05
Rate for Payer: Cash Price	$401.05
Rate for Payer: Devoted Health Medicare	$339.35
Rate for Payer: Hawaii Medical Service Association ABD	$18.78
Rate for Payer: Hawaii Medical Service Association Medicare	$308.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.20
Rate for Payer: Hawaii Western Management Group Commercial	$586.15
Rate for Payer: Health Management Network Commercial	$524.45
Rate for Payer: Humana Medicare	$308.50
Rate for Payer: Kaiser Permanente Commercial	$555.30
Rate for Payer: Kaiser Permanente Medicaid	$314.67
Rate for Payer: Kaiser Permanente Medicare	$308.50
Rate for Payer: MDX Hawaii PPO	$598.49
Rate for Payer: Ohana Health Plan Medicaid	$308.50
Rate for Payer: Ohana Health Plan Medicare	$308.50
Rate for Payer: UnitedHealthcare Medicaid	$18.78
Rate for Payer: UnitedHealthcare Medicare	$308.50
Rate for Payer: University Health Alliance Commercial	$345.52

XR Cholangiogram in OR - Report

Professional

Both

$50.00

Service Code	HCPCS 74300 26
Hospital Charge Code	629737
Hospital Revenue Code	972
Min. Negotiated Rate	$13.06
Max. Negotiated Rate	$42.50
Rate for Payer: AlohaCare Medicaid	$18.78
Rate for Payer: AlohaCare Medicare	$13.06
Rate for Payer: Cash Price	$32.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Devoted Health Medicare	$14.37
Rate for Payer: Hawaii Medical Service Association Medicare	$13.06
Rate for Payer: Health Management Network Commercial	$42.50
Rate for Payer: Kaiser Permanente Commercial	$15.67
Rate for Payer: Kaiser Permanente Medicaid	$15.67
Rate for Payer: Kaiser Permanente Medicare	$15.67
Rate for Payer: Ohana Health Plan Medicaid	$18.78
Rate for Payer: Ohana Health Plan Medicare	$13.06
Rate for Payer: UnitedHealthcare Medicaid	$18.78
Rate for Payer: UnitedHealthcare Medicare	$13.06

XR Clavicle Bilat

Facility

$524.00

Service Code	HCPCS 73000 50
Hospital Charge Code	8211690
Hospital Revenue Code	320
Min. Negotiated Rate	$445.40
Max. Negotiated Rate	$508.28
Rate for Payer: Cash Price	$340.60
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: MDX Hawaii PPO	$508.28

XR Clavicle Bilat

Facility

$524.00

Service Code	HCPCS 73000 50
Hospital Charge Code	8211690
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$508.28
Rate for Payer: AlohaCare Medicaid	$262.00
Rate for Payer: AlohaCare Medicare	$262.00
Rate for Payer: Cash Price	$340.60
Rate for Payer: Cash Price	$340.60
Rate for Payer: Devoted Health Medicare	$288.20
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$262.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$497.80
Rate for Payer: Health Management Network Commercial	$445.40
Rate for Payer: Humana Medicare	$262.00
Rate for Payer: Kaiser Permanente Commercial	$471.60
Rate for Payer: Kaiser Permanente Medicaid	$267.24
Rate for Payer: Kaiser Permanente Medicare	$262.00
Rate for Payer: MDX Hawaii PPO	$508.28
Rate for Payer: Ohana Health Plan Medicaid	$262.00
Rate for Payer: Ohana Health Plan Medicare	$262.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$262.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Clavicle Bilat

Professional

Both

$121.00

Service Code	HCPCS 73000 50
Hospital Charge Code	8211690
Hospital Revenue Code	521
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
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	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
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 Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$246.64
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	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
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: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$303.73
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	$339.46

XR Clavicle Bilat - Report

Professional

Both

$121.00

Service Code	HCPCS 73000 26,50
Hospital Charge Code	8211692
Hospital Revenue Code	972
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$21.78

XR Clavicle Left

Professional

Both

$170.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	1170075
Hospital Revenue Code	521
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$110.50
Rate for Payer: Cash Price	$110.50
Rate for Payer: Cash Price	$110.50
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	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
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 Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$246.64
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	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
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: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$303.73
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	$339.46

XR Clavicle Left

Facility

$430.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	1170075
Hospital Revenue Code	320
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$279.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: MDX Hawaii PPO	$417.10

XR Clavicle Left

Facility

$430.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	1170075
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$417.10
Rate for Payer: AlohaCare Medicaid	$215.00
Rate for Payer: AlohaCare Medicare	$215.00
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$236.50
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$215.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Humana Medicare	$215.00
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: Kaiser Permanente Medicaid	$219.30
Rate for Payer: Kaiser Permanente Medicare	$215.00
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: Ohana Health Plan Medicaid	$215.00
Rate for Payer: Ohana Health Plan Medicare	$215.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$215.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Clavicle Left - Report

Professional

Both

$70.00

Service Code	HCPCS 73000 26,LT
Hospital Charge Code	629753
Hospital Revenue Code	972
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$21.78

XR Clavicle Right

Facility

$430.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$417.10
Rate for Payer: AlohaCare Medicaid	$215.00
Rate for Payer: AlohaCare Medicare	$215.00
Rate for Payer: Cash Price	$279.50
Rate for Payer: Cash Price	$279.50
Rate for Payer: Devoted Health Medicare	$236.50
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Medicare	$215.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$408.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Humana Medicare	$215.00
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: Kaiser Permanente Medicaid	$219.30
Rate for Payer: Kaiser Permanente Medicare	$215.00
Rate for Payer: MDX Hawaii PPO	$417.10
Rate for Payer: Ohana Health Plan Medicaid	$215.00
Rate for Payer: Ohana Health Plan Medicare	$215.00
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$215.00
Rate for Payer: University Health Alliance Commercial	$56.28

XR Clavicle Right

Facility

$430.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	320
Min. Negotiated Rate	$365.50
Max. Negotiated Rate	$417.10
Rate for Payer: Cash Price	$279.50
Rate for Payer: Health Management Network Commercial	$365.50
Rate for Payer: Kaiser Permanente Commercial	$387.00
Rate for Payer: MDX Hawaii PPO	$417.10

XR Clavicle Right

Professional

Both

$170.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	521
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$110.50
Rate for Payer: Cash Price	$110.50
Rate for Payer: Cash Price	$110.50
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	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
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 Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$144.50
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 Commercial	$303.73
Rate for Payer: Kaiser Permanente Medicaid	$434.26
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	$265.97
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Ohana Health Plan Medicaid	$21.78
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 Clavicle Right - Report

Professional

Both

$70.00

Service Code	HCPCS 73000 26,RT
Hospital Charge Code	629755
Hospital Revenue Code	972
Min. Negotiated Rate	$21.78
Max. Negotiated Rate	$59.50
Rate for Payer: AlohaCare Medicaid	$21.78
Rate for Payer: Cash Price	$45.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.71
Rate for Payer: Health Management Network Commercial	$59.50
Rate for Payer: Ohana Health Plan Medicaid	$21.78
Rate for Payer: UnitedHealthcare Medicaid	$21.78

XR Cystogram

Facility

$1,114.00

Service Code	HCPCS 74430
Hospital Charge Code	8221475
Hospital Revenue Code	320
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$1,080.58
Rate for Payer: AlohaCare Medicaid	$557.00
Rate for Payer: AlohaCare Medicare	$557.00
Rate for Payer: Cash Price	$724.10
Rate for Payer: Cash Price	$724.10
Rate for Payer: Devoted Health Medicare	$612.70
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$445.54
Rate for Payer: Hawaii Medical Service Association Medicare	$557.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$356.43
Rate for Payer: Health Management Network Commercial	$946.90
Rate for Payer: Humana Medicare	$557.00
Rate for Payer: Kaiser Permanente Commercial	$1,002.60
Rate for Payer: Kaiser Permanente Medicaid	$568.14
Rate for Payer: Kaiser Permanente Medicare	$557.00
Rate for Payer: MDX Hawaii PPO	$1,080.58
Rate for Payer: Ohana Health Plan Medicaid	$557.00
Rate for Payer: Ohana Health Plan Medicare	$557.00
Rate for Payer: UnitedHealthcare Medicaid	$34.94
Rate for Payer: UnitedHealthcare Medicare	$557.00
Rate for Payer: University Health Alliance Commercial	$148.81

XR Cystogram

Facility

$1,114.00

Service Code	HCPCS 74430
Hospital Charge Code	8221475
Hospital Revenue Code	320
Min. Negotiated Rate	$946.90
Max. Negotiated Rate	$1,080.58
Rate for Payer: Cash Price	$724.10
Rate for Payer: Health Management Network Commercial	$946.90
Rate for Payer: Kaiser Permanente Commercial	$1,002.60
Rate for Payer: MDX Hawaii PPO	$1,080.58

XR Cystogram - Report

Professional

Both

$486.00

Service Code	HCPCS 74430 26
Hospital Charge Code	2425448
Hospital Revenue Code	972
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$413.10
Rate for Payer: AlohaCare Medicaid	$27.15
Rate for Payer: AlohaCare Medicare	$15.30
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cash Price	$315.90
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	$63.84
Rate for Payer: Health Management Network Commercial	$413.10
Rate for Payer: Kaiser Permanente Commercial	$18.36
Rate for Payer: Kaiser Permanente Medicaid	$18.36
Rate for Payer: Kaiser Permanente Medicare	$18.36
Rate for Payer: Ohana Health Plan Medicaid	$27.15
Rate for Payer: Ohana Health Plan Medicare	$15.30
Rate for Payer: UnitedHealthcare Medicaid	$27.15
Rate for Payer: UnitedHealthcare Medicare	$15.30

XR Cystogram/Urethrogram Injection

Facility

$730.00

Service Code	HCPCS 51610
Hospital Charge Code	9803541
Hospital Revenue Code	320
Min. Negotiated Rate	$620.50
Max. Negotiated Rate	$708.10
Rate for Payer: Cash Price	$474.50
Rate for Payer: Health Management Network Commercial	$620.50
Rate for Payer: Kaiser Permanente Commercial	$657.00
Rate for Payer: MDX Hawaii PPO	$708.10

Know your out-of-pocket cost for care.

All Charges