Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

XR TMJ Open and Closed Left

Facility

$419.00

Service Code	HCPCS 70328 LT
Hospital Charge Code	8100061
Hospital Revenue Code	320
Min. Negotiated Rate	$356.15
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$272.35
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: MDX Hawaii PPO	$406.43

XR TMJ Open and Closed Left

Facility

$419.00

Service Code	HCPCS 70328 LT
Hospital Charge Code	8100061
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$406.43
Rate for Payer: AlohaCare Medicaid	$209.50
Rate for Payer: AlohaCare Medicare	$209.50
Rate for Payer: Cash Price	$272.35
Rate for Payer: Cash Price	$272.35
Rate for Payer: Devoted Health Medicare	$230.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$209.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.54
Rate for Payer: Hawaii Western Management Group Commercial	$398.05
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Humana Medicare	$209.50
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: Kaiser Permanente Medicare	$209.50
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: Ohana Health Plan Medicaid	$209.50
Rate for Payer: Ohana Health Plan Medicare	$209.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$209.50
Rate for Payer: University Health Alliance Commercial	$60.09

XR TMJ Open and Closed Left - Report

Professional

Both

$47.00

Service Code	HCPCS 70328 26,LT
Hospital Charge Code	8100062
Hospital Revenue Code	972
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$39.95
Rate for Payer: AlohaCare Medicaid	$23.10
Rate for Payer: Cash Price	$30.55
Rate for Payer: Cash Price	$30.55
Rate for Payer: Hawaii Western Management Group Commercial	$31.78
Rate for Payer: Health Management Network Commercial	$39.95
Rate for Payer: Ohana Health Plan Medicaid	$23.10
Rate for Payer: UnitedHealthcare Medicaid	$23.10

XR TMJ Open and Closed Right

Facility

$419.00

Service Code	HCPCS 70328 RT
Hospital Charge Code	8100063
Hospital Revenue Code	320
Min. Negotiated Rate	$356.15
Max. Negotiated Rate	$406.43
Rate for Payer: Cash Price	$272.35
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: MDX Hawaii PPO	$406.43

XR TMJ Open and Closed Right

Facility

$419.00

Service Code	HCPCS 70328 RT
Hospital Charge Code	8100063
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$406.43
Rate for Payer: AlohaCare Medicaid	$209.50
Rate for Payer: AlohaCare Medicare	$209.50
Rate for Payer: Cash Price	$272.35
Rate for Payer: Cash Price	$272.35
Rate for Payer: Devoted Health Medicare	$230.45
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$209.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.54
Rate for Payer: Hawaii Western Management Group Commercial	$398.05
Rate for Payer: Health Management Network Commercial	$356.15
Rate for Payer: Humana Medicare	$209.50
Rate for Payer: Kaiser Permanente Commercial	$377.10
Rate for Payer: Kaiser Permanente Medicaid	$213.69
Rate for Payer: Kaiser Permanente Medicare	$209.50
Rate for Payer: MDX Hawaii PPO	$406.43
Rate for Payer: Ohana Health Plan Medicaid	$209.50
Rate for Payer: Ohana Health Plan Medicare	$209.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$209.50
Rate for Payer: University Health Alliance Commercial	$60.09

XR TMJ Open and Closed Right - Report

Professional

Both

$121.00

Service Code	HCPCS 70328 26,RT
Hospital Charge Code	8100064
Hospital Revenue Code	972
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$23.10
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$31.78
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$23.10
Rate for Payer: UnitedHealthcare Medicaid	$23.10

XR Toe(s) 2+ Views Left

Professional

Both

$159.00

Service Code	HCPCS 73660
Hospital Charge Code	1170520
Hospital Revenue Code	521
Min. Negotiated Rate	$19.57
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$19.57
Rate for Payer: AlohaCare Medicare	$31.69
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
Rate for Payer: Devoted Health Medicare	$34.86
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	$25.75
Rate for Payer: Health Management Network Commercial	$135.15
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Commercial	$38.03
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	$19.57
Rate for Payer: Ohana Health Plan Medicare	$31.69
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 Toe(s) 2+ Views Left

Facility

$280.00

Service Code	HCPCS 73660
Hospital Charge Code	1170520
Hospital Revenue Code	320
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$182.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: MDX Hawaii PPO	$271.60

XR Toe(s) 2+ Views Left

Facility

$280.00

Service Code	HCPCS 73660
Hospital Charge Code	1170520
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$271.60
Rate for Payer: AlohaCare Medicaid	$140.00
Rate for Payer: AlohaCare Medicare	$140.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Devoted Health Medicare	$154.00
Rate for Payer: Hawaii Medical Service Association ABD	$13.91
Rate for Payer: Hawaii Medical Service Association Commercial	$111.14
Rate for Payer: Hawaii Medical Service Association Medicare	$140.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.94
Rate for Payer: Hawaii Western Management Group Commercial	$88.91
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Humana Medicare	$140.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$142.80
Rate for Payer: Kaiser Permanente Medicare	$140.00
Rate for Payer: MDX Hawaii PPO	$271.60
Rate for Payer: Ohana Health Plan Medicaid	$140.00
Rate for Payer: Ohana Health Plan Medicare	$140.00
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: UnitedHealthcare Medicare	$140.00
Rate for Payer: University Health Alliance Commercial	$53.35

XR Toe(s) 2+ Views Left - Report

Professional

Both

$121.00

Service Code	HCPCS 73660 26,LT
Hospital Charge Code	629919
Hospital Revenue Code	972
Min. Negotiated Rate	$19.57
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$19.57
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$25.75
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$19.57
Rate for Payer: UnitedHealthcare Medicaid	$19.57

XR Toe(s) 2+ Views Right

Professional

Both

$159.00

Service Code	HCPCS 73660 RT
Hospital Charge Code	8111120
Hospital Revenue Code	521
Min. Negotiated Rate	$19.57
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicaid	$19.57
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
Rate for Payer: Cash Price	$103.35
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	$25.75
Rate for Payer: Health Management Network Commercial	$135.15
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	$19.57
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 Toe(s) 2+ Views Right

Facility

$280.00

Service Code	HCPCS 73660 RT
Hospital Charge Code	8111120
Hospital Revenue Code	320
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$271.60
Rate for Payer: AlohaCare Medicaid	$140.00
Rate for Payer: AlohaCare Medicare	$140.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Cash Price	$182.00
Rate for Payer: Devoted Health Medicare	$154.00
Rate for Payer: Hawaii Medical Service Association ABD	$13.91
Rate for Payer: Hawaii Medical Service Association Medicare	$140.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.94
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Humana Medicare	$140.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: Kaiser Permanente Medicaid	$142.80
Rate for Payer: Kaiser Permanente Medicare	$140.00
Rate for Payer: MDX Hawaii PPO	$271.60
Rate for Payer: Ohana Health Plan Medicaid	$140.00
Rate for Payer: Ohana Health Plan Medicare	$140.00
Rate for Payer: UnitedHealthcare Medicaid	$13.91
Rate for Payer: UnitedHealthcare Medicare	$140.00
Rate for Payer: University Health Alliance Commercial	$53.35

XR Toe(s) 2+ Views Right

Facility

$280.00

Service Code	HCPCS 73660 RT
Hospital Charge Code	8111120
Hospital Revenue Code	320
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$271.60
Rate for Payer: Cash Price	$182.00
Rate for Payer: Health Management Network Commercial	$238.00
Rate for Payer: Kaiser Permanente Commercial	$252.00
Rate for Payer: MDX Hawaii PPO	$271.60

XR Toe(s) 2+ Views Right - Report

Professional

Both

$121.00

Service Code	HCPCS 73660 26,RT
Hospital Charge Code	8111121
Hospital Revenue Code	972
Min. Negotiated Rate	$19.57
Max. Negotiated Rate	$102.85
Rate for Payer: AlohaCare Medicaid	$19.57
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cash Price	$78.65
Rate for Payer: Hawaii Western Management Group Commercial	$25.75
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Ohana Health Plan Medicaid	$19.57
Rate for Payer: UnitedHealthcare Medicaid	$19.57

XR Upper Extremity Infant (0-1yr) Bilat

Facility

$435.00

Service Code	HCPCS 73092 50
Hospital Charge Code	1170556
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$421.95
Rate for Payer: AlohaCare Medicaid	$217.50
Rate for Payer: AlohaCare Medicare	$217.50
Rate for Payer: Cash Price	$282.75
Rate for Payer: Cash Price	$282.75
Rate for Payer: Devoted Health Medicare	$239.25
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$217.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$413.25
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Humana Medicare	$217.50
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: Kaiser Permanente Medicare	$217.50
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: Ohana Health Plan Medicaid	$217.50
Rate for Payer: Ohana Health Plan Medicare	$217.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$217.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Upper Extremity Infant (0-1yr) Bilat

Facility

$435.00

Service Code	HCPCS 73092 50
Hospital Charge Code	1170556
Hospital Revenue Code	320
Min. Negotiated Rate	$369.75
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$282.75
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: MDX Hawaii PPO	$421.95

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

Professional

Both

$86.00

Service Code	HCPCS 73092 26,50
Hospital Charge Code	613589
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 Upper Extremity Infant (0-1yr) Left

Facility

$435.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	1170558
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$421.95
Rate for Payer: AlohaCare Medicaid	$217.50
Rate for Payer: AlohaCare Medicare	$217.50
Rate for Payer: Cash Price	$282.75
Rate for Payer: Cash Price	$282.75
Rate for Payer: Devoted Health Medicare	$239.25
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$217.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$413.25
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Humana Medicare	$217.50
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: Kaiser Permanente Medicare	$217.50
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: Ohana Health Plan Medicaid	$217.50
Rate for Payer: Ohana Health Plan Medicare	$217.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$217.50
Rate for Payer: University Health Alliance Commercial	$56.28

XR Upper Extremity Infant (0-1yr) Left

Facility

$435.00

Service Code	HCPCS 73092 LT
Hospital Charge Code	1170558
Hospital Revenue Code	320
Min. Negotiated Rate	$369.75
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$282.75
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: MDX Hawaii PPO	$421.95

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

Professional

Both

$86.00

Service Code	HCPCS 73092 26,LT
Hospital Charge Code	613591
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 Upper Extremity Infant (0-1yr) Right

Facility

$435.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	1170560
Hospital Revenue Code	320
Min. Negotiated Rate	$369.75
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$282.75
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: MDX Hawaii PPO	$421.95

XR Upper Extremity Infant (0-1yr) Right

Facility

$435.00

Service Code	HCPCS 73092 RT
Hospital Charge Code	1170560
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$421.95
Rate for Payer: AlohaCare Medicaid	$217.50
Rate for Payer: AlohaCare Medicare	$217.50
Rate for Payer: Cash Price	$282.75
Rate for Payer: Cash Price	$282.75
Rate for Payer: Devoted Health Medicare	$239.25
Rate for Payer: Hawaii Medical Service Association ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Medicare	$217.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.57
Rate for Payer: Hawaii Western Management Group Commercial	$413.25
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Humana Medicare	$217.50
Rate for Payer: Kaiser Permanente Commercial	$391.50
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: Kaiser Permanente Medicare	$217.50
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: Ohana Health Plan Medicaid	$217.50
Rate for Payer: Ohana Health Plan Medicare	$217.50
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$217.50
Rate for Payer: University Health Alliance Commercial	$56.28

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

Professional

Both

$86.00

Service Code	HCPCS 73092 26,RT
Hospital Charge Code	613593
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 Upper GI

Facility

$880.00

Service Code	HCPCS 74240
Hospital Charge Code	1170562
Hospital Revenue Code	320
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$572.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: MDX Hawaii PPO	$853.60

XR Upper GI

Facility

$880.00

Service Code	HCPCS 74240
Hospital Charge Code	1170562
Hospital Revenue Code	320
Min. Negotiated Rate	$48.23
Max. Negotiated Rate	$853.60
Rate for Payer: UnitedHealthcare Medicaid	$48.23
Rate for Payer: AlohaCare Medicaid	$440.00
Rate for Payer: AlohaCare Medicare	$440.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cash Price	$572.00
Rate for Payer: Devoted Health Medicare	$484.00
Rate for Payer: Hawaii Medical Service Association ABD	$48.23
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$440.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$52.32
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Humana Medicare	$440.00
Rate for Payer: Kaiser Permanente Commercial	$792.00
Rate for Payer: Kaiser Permanente Medicaid	$448.80
Rate for Payer: Kaiser Permanente Medicare	$440.00
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: Ohana Health Plan Medicaid	$440.00
Rate for Payer: Ohana Health Plan Medicare	$440.00
Rate for Payer: UnitedHealthcare Medicare	$440.00
Rate for Payer: University Health Alliance Commercial	$208.88

Know your out-of-pocket cost for care.

All Charges