CMS Price Transparency Data

X-ray, pelvis

Facility: Samuel Mahelona Memorial Hospital

Billing Code: 72170 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 72170
Insurance Median: $193
Cash Discount Price: $100
vs. Medicare Baseline: 1.81x Medicare

The contracted insurance negotiated median rate for a X-ray, pelvis at Samuel Mahelona Memorial Hospital is $193. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $100. Compared to the federal Medicare reimbursement reference rate of $106.81, this hospital’s rate is 1.81x the Medicare baseline. Located in 4800 Kawaihau Road, Kapaa, HI.

Cash / Self-Pay

$100

Average discount available for prompt cash payment at this facility.

Insurance Median

$193

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$106.81

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $106.81 (100%)

Cash / Self-Pay: $100 (94%)

Insurance Median: $193 (181%)

Cash: $100 (94% of Medicare)

Ins. Median: $193 (181% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $106.81 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Devoted Health	$9 - $212	8%
Ohana Health Plan	$9 - $193	8%
UnitedHealthcare	$9 - $434	8%
Alohacare	$9 - $193	8%
Hawaii Medical Service Association	$9 - $434	8%
Kaiser Permanente	$10 - $434	9%
Hawaii Western Management Group	$32 - $107	30%
University Health Alliance	$55	51%
Health Management Network	$60 - $328	56%
Humana	$193	181%
Mdx Hawaii	$374	350%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $100.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 72170.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Samuel Mahelona Memorial Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 72170.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.