Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR Lower Extremity Infant (0-1yr) Bilat

Facility

$381.00

Service Code	HCPCS 73592 50
Hospital Charge Code	1170295
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$369.57
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$190.50
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$209.55
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$190.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$190.50
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$190.50
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$190.50
Rate for Payer: Ohana Health Plan Medicare	$190.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$190.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Lower Extremity Infant (0-1yr) Bilat

Facility

$381.00

Service Code	HCPCS 73592 50
Hospital Charge Code	1170295
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

XR Lower Extremity Infant (0-1yr) Bilat - Report

Professional

Both

$86.00

Service Code	HCPCS 73592 26,50
Hospital Charge Code	630346
Hospital Revenue Code	972
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$21.09
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$21.09
Rate for Payer: UnitedHealthcare Medicaid	$21.09

XR Lower Extremity Infant (0-1yr) Left

Facility

$381.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	1170297
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$369.57
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$190.50
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$209.55
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$190.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$190.50
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$190.50
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$190.50
Rate for Payer: Ohana Health Plan Medicare	$190.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$190.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Lower Extremity Infant (0-1yr) Left

Facility

$381.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	1170297
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

XR Lower Extremity Infant (0-1yr) Left - Report

Professional

Both

$86.00

Service Code	HCPCS 73592 26,LT
Hospital Charge Code	630344
Hospital Revenue Code	972
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$21.09
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$21.09
Rate for Payer: UnitedHealthcare Medicaid	$21.09

XR Lower Extremity Infant (0-1yr) Right

Facility

$381.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	1170299
Hospital Revenue Code	320
Min. Negotiated Rate	$323.85
Max. Negotiated Rate	$369.57
Rate for Payer: Cash Price	$247.65
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: MDX Hawaii PPO	$369.57

XR Lower Extremity Infant (0-1yr) Right

Facility

$381.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	1170299
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$369.57
Rate for Payer: AlohaCare Medicaid	$190.50
Rate for Payer: AlohaCare Medicare	$190.50
Rate for Payer: Cash Price	$247.65
Rate for Payer: Cash Price	$247.65
Rate for Payer: Devoted Health Medicare	$209.55
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$190.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$361.95
Rate for Payer: Health Management Network Commercial	$323.85
Rate for Payer: Humana Medicare	$190.50
Rate for Payer: Kaiser Permanente Commercial	$342.90
Rate for Payer: Kaiser Permanente Medicaid	$194.31
Rate for Payer: Kaiser Permanente Medicare	$190.50
Rate for Payer: MDX Hawaii PPO	$369.57
Rate for Payer: Ohana Health Plan Medicaid	$190.50
Rate for Payer: Ohana Health Plan Medicare	$190.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$190.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Lower Extremity Infant (0-1yr) Right - Report

Professional

Both

$86.00

Service Code	HCPCS 73592 26,RT
Hospital Charge Code	630342
Hospital Revenue Code	972
Min. Negotiated Rate	$21.09
Max. Negotiated Rate	$73.10
Rate for Payer: AlohaCare Medicaid	$21.09
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Hawaii Western Management Group Commercial	$30.36
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Ohana Health Plan Medicaid	$21.09
Rate for Payer: UnitedHealthcare Medicaid	$21.09

XR Mandible Complete 4+ Views

Facility

$635.00

Service Code	HCPCS 70110
Hospital Charge Code	1170301
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$615.95
Rate for Payer: AlohaCare Medicaid	$317.50
Rate for Payer: AlohaCare Medicare	$317.50
Rate for Payer: Cash Price	$412.75
Rate for Payer: Cash Price	$412.75
Rate for Payer: Devoted Health Medicare	$349.25
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$317.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.35
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$539.75
Rate for Payer: Humana Medicare	$317.50
Rate for Payer: Kaiser Permanente Commercial	$571.50
Rate for Payer: Kaiser Permanente Medicaid	$323.85
Rate for Payer: Kaiser Permanente Medicare	$317.50
Rate for Payer: MDX Hawaii PPO	$615.95
Rate for Payer: Ohana Health Plan Medicaid	$317.50
Rate for Payer: Ohana Health Plan Medicare	$317.50
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$317.50
Rate for Payer: University Health Alliance Commercial	$78.16

XR Mandible Complete 4+ Views

Facility

$635.00

Service Code	HCPCS 70110
Hospital Charge Code	1170301
Hospital Revenue Code	320
Min. Negotiated Rate	$539.75
Max. Negotiated Rate	$615.95
Rate for Payer: Cash Price	$412.75
Rate for Payer: Health Management Network Commercial	$539.75
Rate for Payer: Kaiser Permanente Commercial	$571.50
Rate for Payer: MDX Hawaii PPO	$615.95

XR Mandible Complete 4+ Views

Professional

Both

$145.00

Service Code	HCPCS 70110
Hospital Charge Code	1170301
Hospital Revenue Code	521
Min. Negotiated Rate	$29.08
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$29.08
Rate for Payer: AlohaCare Medicare	$47.52
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Devoted Health Medicare	$52.27
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
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	$41.25
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$57.02
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	$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: Kaiser Permanente Medicare	$265.97
Rate for Payer: Ohana Health Plan Medicaid	$29.08
Rate for Payer: Ohana Health Plan Medicare	$47.52
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 Mandible Complete 4+ Views - Report

Professional

Both

$90.00

Service Code	HCPCS 70110 26
Hospital Charge Code	630340
Hospital Revenue Code	972
Min. Negotiated Rate	$12.01
Max. Negotiated Rate	$76.50
Rate for Payer: AlohaCare Medicaid	$29.08
Rate for Payer: AlohaCare Medicare	$12.01
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Devoted Health Medicare	$13.21
Rate for Payer: Hawaii Medical Service Association Medicare	$12.01
Rate for Payer: Hawaii Western Management Group Commercial	$41.25
Rate for Payer: Health Management Network Commercial	$76.50
Rate for Payer: Kaiser Permanente Commercial	$14.41
Rate for Payer: Kaiser Permanente Medicaid	$14.41
Rate for Payer: Kaiser Permanente Medicare	$14.41
Rate for Payer: Ohana Health Plan Medicaid	$29.08
Rate for Payer: Ohana Health Plan Medicare	$12.01
Rate for Payer: UnitedHealthcare Medicaid	$29.08
Rate for Payer: UnitedHealthcare Medicare	$12.01

XR Mandible Less Than 4 Views

Professional

Both

$121.00

Service Code	HCPCS 70100
Hospital Charge Code	1170303
Hospital Revenue Code	521
Min. Negotiated Rate	$26.08
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$26.08
Rate for Payer: AlohaCare Medicare	$44.76
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Devoted Health Medicare	$49.24
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
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 Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$33.12
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$53.71
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	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
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: Ohana Health Plan Medicaid	$26.08
Rate for Payer: Ohana Health Plan Medicare	$44.76
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$339.46

XR Mandible Less Than 4 Views

Facility

$521.00

Service Code	HCPCS 70100
Hospital Charge Code	1170303
Hospital Revenue Code	320
Min. Negotiated Rate	$442.85
Max. Negotiated Rate	$505.37
Rate for Payer: Cash Price	$338.65
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: MDX Hawaii PPO	$505.37

XR Mandible Less Than 4 Views

Facility

$521.00

Service Code	HCPCS 70100
Hospital Charge Code	1170303
Hospital Revenue Code	320
Min. Negotiated Rate	$17.04
Max. Negotiated Rate	$505.37
Rate for Payer: AlohaCare Medicaid	$260.50
Rate for Payer: AlohaCare Medicare	$260.50
Rate for Payer: Cash Price	$338.65
Rate for Payer: Cash Price	$338.65
Rate for Payer: Devoted Health Medicare	$286.55
Rate for Payer: Hawaii Medical Service Association ABD	$17.04
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$260.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.57
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$442.85
Rate for Payer: Humana Medicare	$260.50
Rate for Payer: Kaiser Permanente Commercial	$468.90
Rate for Payer: Kaiser Permanente Medicaid	$265.71
Rate for Payer: Kaiser Permanente Medicare	$260.50
Rate for Payer: MDX Hawaii PPO	$505.37
Rate for Payer: Ohana Health Plan Medicaid	$260.50
Rate for Payer: Ohana Health Plan Medicare	$260.50
Rate for Payer: UnitedHealthcare Medicaid	$17.04
Rate for Payer: UnitedHealthcare Medicare	$260.50
Rate for Payer: University Health Alliance Commercial	$61.70

XR Mandible Less Than 4 Views - Report

Professional

Both

$68.00

Service Code	HCPCS 70100 26
Hospital Charge Code	630338
Hospital Revenue Code	972
Min. Negotiated Rate	$9.24
Max. Negotiated Rate	$57.80
Rate for Payer: AlohaCare Medicaid	$26.08
Rate for Payer: AlohaCare Medicare	$9.24
Rate for Payer: Cash Price	$44.20
Rate for Payer: Cash Price	$44.20
Rate for Payer: Devoted Health Medicare	$10.16
Rate for Payer: Hawaii Medical Service Association Medicare	$9.24
Rate for Payer: Hawaii Western Management Group Commercial	$33.12
Rate for Payer: Health Management Network Commercial	$57.80
Rate for Payer: Kaiser Permanente Commercial	$11.09
Rate for Payer: Kaiser Permanente Medicaid	$11.09
Rate for Payer: Kaiser Permanente Medicare	$11.09
Rate for Payer: Ohana Health Plan Medicaid	$26.08
Rate for Payer: Ohana Health Plan Medicare	$9.24
Rate for Payer: UnitedHealthcare Medicaid	$26.08
Rate for Payer: UnitedHealthcare Medicare	$9.24

XR Mastoids < 3 Views Left

Facility

$319.00

Service Code	HCPCS 70120 LT
Hospital Charge Code	8111116
Hospital Revenue Code	320
Min. Negotiated Rate	$271.15
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$207.35
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43

XR Mastoids < 3 Views Left

Facility

$319.00

Service Code	HCPCS 70120 LT
Hospital Charge Code	8111116
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$159.50
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Devoted Health Medicare	$175.45
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Medicare	$159.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.45
Rate for Payer: Hawaii Western Management Group Commercial	$303.05
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$159.50
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$159.50
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$159.50
Rate for Payer: Ohana Health Plan Medicare	$159.50
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$159.50
Rate for Payer: University Health Alliance Commercial	$69.12

XR Mastoids < 3 Views Left - Report

Professional

Both

$145.00

Service Code	HCPCS 70120 26,LT
Hospital Charge Code	8111117
Hospital Revenue Code	972
Min. Negotiated Rate	$25.62
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$25.62
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$37.46
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$25.62
Rate for Payer: UnitedHealthcare Medicaid	$25.62

XR Mastoids < 3 Views Right

Facility

$319.00

Service Code	HCPCS 70120 RT
Hospital Charge Code	8111118
Hospital Revenue Code	320
Min. Negotiated Rate	$271.15
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$207.35
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43

XR Mastoids < 3 Views Right

Facility

$319.00

Service Code	HCPCS 70120 RT
Hospital Charge Code	8111118
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$159.50
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Devoted Health Medicare	$175.45
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Medicare	$159.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.45
Rate for Payer: Hawaii Western Management Group Commercial	$303.05
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$159.50
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$159.50
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$159.50
Rate for Payer: Ohana Health Plan Medicare	$159.50
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$159.50
Rate for Payer: University Health Alliance Commercial	$69.12

XR Mastoids < 3 Views Right - Report

Professional

Both

$145.00

Service Code	HCPCS 70120 26,RT
Hospital Charge Code	8111119
Hospital Revenue Code	972
Min. Negotiated Rate	$25.62
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$25.62
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$37.46
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$25.62
Rate for Payer: UnitedHealthcare Medicaid	$25.62

XR Mastoids Complete

Facility

$319.00

Service Code	HCPCS 70120 50
Hospital Charge Code	1170315
Hospital Revenue Code	320
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$159.50
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Devoted Health Medicare	$175.45
Rate for Payer: Hawaii Medical Service Association ABD	$20.40
Rate for Payer: Hawaii Medical Service Association Medicare	$159.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22.45
Rate for Payer: Hawaii Western Management Group Commercial	$303.05
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$159.50
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$159.50
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$159.50
Rate for Payer: Ohana Health Plan Medicare	$159.50
Rate for Payer: UnitedHealthcare Medicaid	$20.40
Rate for Payer: UnitedHealthcare Medicare	$159.50
Rate for Payer: University Health Alliance Commercial	$69.12

XR Mastoids Complete

Facility

$319.00

Service Code	HCPCS 70120 50
Hospital Charge Code	1170315
Hospital Revenue Code	320
Min. Negotiated Rate	$271.15
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$207.35
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43

Know your out-of-pocket cost for care.

All Charges