Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CT Angio Brain/Head - Report

Professional

Both

$308.00

Service Code	HCPCS 70496 26
Hospital Charge Code	629763
Hospital Revenue Code	972
Min. Negotiated Rate	$81.64
Max. Negotiated Rate	$425.61
Rate for Payer: AlohaCare Medicaid	$188.21
Rate for Payer: AlohaCare Medicare	$81.64
Rate for Payer: Cash Price	$200.20
Rate for Payer: Cash Price	$200.20
Rate for Payer: Devoted Health Medicare	$89.80
Rate for Payer: Hawaii Medical Service Association Medicare	$81.64
Rate for Payer: Hawaii Western Management Group Commercial	$425.61
Rate for Payer: Health Management Network Commercial	$261.80
Rate for Payer: Kaiser Permanente Commercial	$89.80
Rate for Payer: Kaiser Permanente Medicaid	$89.80
Rate for Payer: Kaiser Permanente Medicare	$89.80
Rate for Payer: Ohana Health Plan Medicaid	$188.21
Rate for Payer: Ohana Health Plan Medicare	$81.64
Rate for Payer: UnitedHealthcare Medicaid	$188.21
Rate for Payer: UnitedHealthcare Medicare	$81.64

CT Angio Chest

Facility

$2,332.00

Service Code	HCPCS 71275
Hospital Charge Code	1167863
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$2,262.04
Rate for Payer: AlohaCare Medicaid	$1,166.00
Rate for Payer: AlohaCare Medicare	$1,166.00
Rate for Payer: Cash Price	$1,515.80
Rate for Payer: Cash Price	$1,515.80
Rate for Payer: Devoted Health Medicare	$1,282.60
Rate for Payer: Hawaii Medical Service Association ABD	$320.86
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,166.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$437.53
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$1,982.20
Rate for Payer: Humana Medicare	$1,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,098.80
Rate for Payer: Kaiser Permanente Medicaid	$1,189.32
Rate for Payer: Kaiser Permanente Medicare	$1,166.00
Rate for Payer: MDX Hawaii PPO	$2,262.04
Rate for Payer: Ohana Health Plan Medicaid	$1,166.00
Rate for Payer: Ohana Health Plan Medicare	$1,166.00
Rate for Payer: UnitedHealthcare Medicaid	$320.86
Rate for Payer: UnitedHealthcare Medicare	$1,166.00
Rate for Payer: University Health Alliance Commercial	$860.75

CT Angio Chest

Facility

$2,332.00

Service Code	HCPCS 71275
Hospital Charge Code	1167863
Hospital Revenue Code	352
Min. Negotiated Rate	$1,982.20
Max. Negotiated Rate	$2,262.04
Rate for Payer: Cash Price	$1,515.80
Rate for Payer: Health Management Network Commercial	$1,982.20
Rate for Payer: Kaiser Permanente Commercial	$2,098.80
Rate for Payer: MDX Hawaii PPO	$2,262.04

CT Angio Chest/Abdomen

Facility

$6,714.00

Service Code	HCPCS 71275
Hospital Charge Code	8393942
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$6,512.58
Rate for Payer: AlohaCare Medicaid	$3,357.00
Rate for Payer: AlohaCare Medicare	$3,357.00
Rate for Payer: Cash Price	$4,364.10
Rate for Payer: Cash Price	$4,364.10
Rate for Payer: Devoted Health Medicare	$3,692.70
Rate for Payer: Hawaii Medical Service Association ABD	$320.86
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,357.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$437.53
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$5,706.90
Rate for Payer: Humana Medicare	$3,357.00
Rate for Payer: Kaiser Permanente Commercial	$6,042.60
Rate for Payer: Kaiser Permanente Medicaid	$3,424.14
Rate for Payer: Kaiser Permanente Medicare	$3,357.00
Rate for Payer: MDX Hawaii PPO	$6,512.58
Rate for Payer: Ohana Health Plan Medicaid	$3,357.00
Rate for Payer: Ohana Health Plan Medicare	$3,357.00
Rate for Payer: UnitedHealthcare Medicaid	$320.86
Rate for Payer: UnitedHealthcare Medicare	$3,357.00
Rate for Payer: University Health Alliance Commercial	$860.75

CT Angio Chest/Abdomen

Facility

$6,714.00

Service Code	HCPCS 71275
Hospital Charge Code	8393942
Hospital Revenue Code	352
Min. Negotiated Rate	$5,706.90
Max. Negotiated Rate	$6,512.58
Rate for Payer: Cash Price	$4,364.10
Rate for Payer: Health Management Network Commercial	$5,706.90
Rate for Payer: Kaiser Permanente Commercial	$6,042.60
Rate for Payer: MDX Hawaii PPO	$6,512.58

CT Angio Chest/Abdomen - Report

Professional

Both

$479.00

Service Code	HCPCS 71275 26
Hospital Charge Code	8393944
Hospital Revenue Code	972
Min. Negotiated Rate	$84.79
Max. Negotiated Rate	$453.86
Rate for Payer: AlohaCare Medicaid	$191.79
Rate for Payer: AlohaCare Medicare	$84.79
Rate for Payer: Cash Price	$311.35
Rate for Payer: Cash Price	$311.35
Rate for Payer: Devoted Health Medicare	$93.27
Rate for Payer: Hawaii Medical Service Association Medicare	$84.79
Rate for Payer: Hawaii Western Management Group Commercial	$453.86
Rate for Payer: Health Management Network Commercial	$407.15
Rate for Payer: Kaiser Permanente Commercial	$93.27
Rate for Payer: Kaiser Permanente Medicaid	$93.27
Rate for Payer: Kaiser Permanente Medicare	$93.27
Rate for Payer: Ohana Health Plan Medicaid	$191.79
Rate for Payer: Ohana Health Plan Medicare	$84.79
Rate for Payer: UnitedHealthcare Medicaid	$191.79
Rate for Payer: UnitedHealthcare Medicare	$84.79

CT Angio Chest PE + Abd/Pelvis w/ Cont

Facility

$7,281.00

Service Code	HCPCS 71275
Hospital Charge Code	8468641
Hospital Revenue Code	352
Min. Negotiated Rate	$6,188.85
Max. Negotiated Rate	$7,062.57
Rate for Payer: Cash Price	$4,732.65
Rate for Payer: Health Management Network Commercial	$6,188.85
Rate for Payer: Kaiser Permanente Commercial	$6,552.90
Rate for Payer: MDX Hawaii PPO	$7,062.57

CT Angio Chest PE + Abd/Pelvis w/ Cont

Facility

$7,281.00

Service Code	HCPCS 71275
Hospital Charge Code	8468641
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$7,062.57
Rate for Payer: AlohaCare Medicaid	$3,640.50
Rate for Payer: AlohaCare Medicare	$3,640.50
Rate for Payer: Cash Price	$4,732.65
Rate for Payer: Cash Price	$4,732.65
Rate for Payer: Devoted Health Medicare	$4,004.55
Rate for Payer: Hawaii Medical Service Association ABD	$320.86
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,640.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$437.53
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$6,188.85
Rate for Payer: Humana Medicare	$3,640.50
Rate for Payer: Kaiser Permanente Commercial	$6,552.90
Rate for Payer: Kaiser Permanente Medicaid	$3,713.31
Rate for Payer: Kaiser Permanente Medicare	$3,640.50
Rate for Payer: MDX Hawaii PPO	$7,062.57
Rate for Payer: Ohana Health Plan Medicaid	$3,640.50
Rate for Payer: Ohana Health Plan Medicare	$3,640.50
Rate for Payer: UnitedHealthcare Medicaid	$320.86
Rate for Payer: UnitedHealthcare Medicare	$3,640.50
Rate for Payer: University Health Alliance Commercial	$860.75

CT Angio Chest PE + Abd/Pelvis w/ Cont - Report

Professional

Both

$479.00

Service Code	HCPCS 71275 26
Hospital Charge Code	8468643
Hospital Revenue Code	972
Min. Negotiated Rate	$84.79
Max. Negotiated Rate	$453.86
Rate for Payer: AlohaCare Medicaid	$191.79
Rate for Payer: AlohaCare Medicare	$84.79
Rate for Payer: Cash Price	$311.35
Rate for Payer: Cash Price	$311.35
Rate for Payer: Devoted Health Medicare	$93.27
Rate for Payer: Hawaii Medical Service Association Medicare	$84.79
Rate for Payer: Hawaii Western Management Group Commercial	$453.86
Rate for Payer: Health Management Network Commercial	$407.15
Rate for Payer: Kaiser Permanente Commercial	$93.27
Rate for Payer: Kaiser Permanente Medicaid	$93.27
Rate for Payer: Kaiser Permanente Medicare	$93.27
Rate for Payer: Ohana Health Plan Medicaid	$191.79
Rate for Payer: Ohana Health Plan Medicare	$84.79
Rate for Payer: UnitedHealthcare Medicaid	$191.79
Rate for Payer: UnitedHealthcare Medicare	$84.79

CT Angio Chest - Report

Professional

Both

$318.00

Service Code	HCPCS 71275 26
Hospital Charge Code	629701
Hospital Revenue Code	972
Min. Negotiated Rate	$84.79
Max. Negotiated Rate	$453.86
Rate for Payer: AlohaCare Medicaid	$191.79
Rate for Payer: AlohaCare Medicare	$84.79
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$93.27
Rate for Payer: Hawaii Medical Service Association Medicare	$84.79
Rate for Payer: Hawaii Western Management Group Commercial	$453.86
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Kaiser Permanente Commercial	$93.27
Rate for Payer: Kaiser Permanente Medicaid	$93.27
Rate for Payer: Kaiser Permanente Medicare	$93.27
Rate for Payer: Ohana Health Plan Medicaid	$191.79
Rate for Payer: Ohana Health Plan Medicare	$84.79
Rate for Payer: UnitedHealthcare Medicaid	$191.79
Rate for Payer: UnitedHealthcare Medicare	$84.79

CT Angio Lower Extremity Bilateral

Facility

$1,977.00

Service Code	HCPCS 73706 50
Hospital Charge Code	8211231
Hospital Revenue Code	352
Min. Negotiated Rate	$1,680.45
Max. Negotiated Rate	$1,917.69
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Kaiser Permanente Commercial	$1,779.30
Rate for Payer: MDX Hawaii PPO	$1,917.69

CT Angio Lower Extremity Bilateral

Facility

$1,977.00

Service Code	HCPCS 73706 50
Hospital Charge Code	8211231
Hospital Revenue Code	352
Min. Negotiated Rate	$284.73
Max. Negotiated Rate	$1,917.69
Rate for Payer: AlohaCare Medicaid	$988.50
Rate for Payer: AlohaCare Medicare	$988.50
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Devoted Health Medicare	$1,087.35
Rate for Payer: Hawaii Medical Service Association ABD	$284.73
Rate for Payer: Hawaii Medical Service Association Medicare	$988.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$388.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,878.15
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Humana Medicare	$988.50
Rate for Payer: Kaiser Permanente Commercial	$1,779.30
Rate for Payer: Kaiser Permanente Medicaid	$1,008.27
Rate for Payer: Kaiser Permanente Medicare	$988.50
Rate for Payer: MDX Hawaii PPO	$1,917.69
Rate for Payer: Ohana Health Plan Medicaid	$988.50
Rate for Payer: Ohana Health Plan Medicare	$988.50
Rate for Payer: UnitedHealthcare Medicaid	$284.73
Rate for Payer: UnitedHealthcare Medicare	$988.50
Rate for Payer: University Health Alliance Commercial	$859.34

CT Angio Lower Extremity Bilateral - Report

Professional

Both

$361.00

Service Code	HCPCS 73706 26,50
Hospital Charge Code	8211233
Hospital Revenue Code	972
Min. Negotiated Rate	$220.81
Max. Negotiated Rate	$397.81
Rate for Payer: AlohaCare Medicaid	$220.81
Rate for Payer: Cash Price	$234.65
Rate for Payer: Cash Price	$234.65
Rate for Payer: Hawaii Western Management Group Commercial	$397.81
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Ohana Health Plan Medicaid	$220.81
Rate for Payer: UnitedHealthcare Medicaid	$220.81

CT Angio Lower Extremity Left

Facility

$1,977.00

Service Code	HCPCS 73706 LT
Hospital Charge Code	1167875
Hospital Revenue Code	352
Min. Negotiated Rate	$284.73
Max. Negotiated Rate	$1,917.69
Rate for Payer: AlohaCare Medicaid	$988.50
Rate for Payer: AlohaCare Medicare	$988.50
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Devoted Health Medicare	$1,087.35
Rate for Payer: Hawaii Medical Service Association ABD	$284.73
Rate for Payer: Hawaii Medical Service Association Medicare	$988.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$388.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,878.15
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Humana Medicare	$988.50
Rate for Payer: Kaiser Permanente Commercial	$1,779.30
Rate for Payer: Kaiser Permanente Medicaid	$1,008.27
Rate for Payer: Kaiser Permanente Medicare	$988.50
Rate for Payer: MDX Hawaii PPO	$1,917.69
Rate for Payer: Ohana Health Plan Medicaid	$988.50
Rate for Payer: Ohana Health Plan Medicare	$988.50
Rate for Payer: UnitedHealthcare Medicaid	$284.73
Rate for Payer: UnitedHealthcare Medicare	$988.50
Rate for Payer: University Health Alliance Commercial	$859.34

CT Angio Lower Extremity Left

Facility

$1,977.00

Service Code	HCPCS 73706 LT
Hospital Charge Code	1167875
Hospital Revenue Code	352
Min. Negotiated Rate	$1,680.45
Max. Negotiated Rate	$1,917.69
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Kaiser Permanente Commercial	$1,779.30
Rate for Payer: MDX Hawaii PPO	$1,917.69

CT Angio Lower Extremity Left - Report

Professional

Both

$361.00

Service Code	HCPCS 73706 26,LT
Hospital Charge Code	629767
Hospital Revenue Code	972
Min. Negotiated Rate	$220.81
Max. Negotiated Rate	$397.81
Rate for Payer: AlohaCare Medicaid	$220.81
Rate for Payer: Cash Price	$234.65
Rate for Payer: Cash Price	$234.65
Rate for Payer: Hawaii Western Management Group Commercial	$397.81
Rate for Payer: Health Management Network Commercial	$306.85
Rate for Payer: Ohana Health Plan Medicaid	$220.81
Rate for Payer: UnitedHealthcare Medicaid	$220.81

CT Angio Lower Extremity Right

Facility

$1,977.00

Service Code	HCPCS 73706 RT
Hospital Charge Code	1167877
Hospital Revenue Code	352
Min. Negotiated Rate	$1,680.45
Max. Negotiated Rate	$1,917.69
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Kaiser Permanente Commercial	$1,779.30
Rate for Payer: MDX Hawaii PPO	$1,917.69

CT Angio Lower Extremity Right

Facility

$1,977.00

Service Code	HCPCS 73706 RT
Hospital Charge Code	1167877
Hospital Revenue Code	352
Min. Negotiated Rate	$284.73
Max. Negotiated Rate	$1,917.69
Rate for Payer: AlohaCare Medicaid	$988.50
Rate for Payer: AlohaCare Medicare	$988.50
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Cash Price	$1,285.05
Rate for Payer: Devoted Health Medicare	$1,087.35
Rate for Payer: Hawaii Medical Service Association ABD	$284.73
Rate for Payer: Hawaii Medical Service Association Medicare	$988.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$388.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,878.15
Rate for Payer: Health Management Network Commercial	$1,680.45
Rate for Payer: Humana Medicare	$988.50
Rate for Payer: Kaiser Permanente Commercial	$1,779.30
Rate for Payer: Kaiser Permanente Medicaid	$1,008.27
Rate for Payer: Kaiser Permanente Medicare	$988.50
Rate for Payer: MDX Hawaii PPO	$1,917.69
Rate for Payer: Ohana Health Plan Medicaid	$988.50
Rate for Payer: Ohana Health Plan Medicare	$988.50
Rate for Payer: UnitedHealthcare Medicaid	$284.73
Rate for Payer: UnitedHealthcare Medicare	$988.50
Rate for Payer: University Health Alliance Commercial	$859.34

CT Angio Lower Extremity Right - Report

Professional

Both

$266.00

Service Code	HCPCS 73706 26,RT
Hospital Charge Code	629769
Hospital Revenue Code	972
Min. Negotiated Rate	$220.81
Max. Negotiated Rate	$397.81
Rate for Payer: AlohaCare Medicaid	$220.81
Rate for Payer: Cash Price	$172.90
Rate for Payer: Cash Price	$172.90
Rate for Payer: Hawaii Western Management Group Commercial	$397.81
Rate for Payer: Health Management Network Commercial	$226.10
Rate for Payer: Ohana Health Plan Medicaid	$220.81
Rate for Payer: UnitedHealthcare Medicaid	$220.81

CT Angio Neck

Facility

$1,767.00

Service Code	HCPCS 70498
Hospital Charge Code	1167879
Hospital Revenue Code	351
Min. Negotiated Rate	$1,501.95
Max. Negotiated Rate	$1,713.99
Rate for Payer: Cash Price	$1,148.55
Rate for Payer: Health Management Network Commercial	$1,501.95
Rate for Payer: Kaiser Permanente Commercial	$1,590.30
Rate for Payer: MDX Hawaii PPO	$1,713.99

CT Angio Neck

Facility

$1,767.00

Service Code	HCPCS 70498
Hospital Charge Code	1167879
Hospital Revenue Code	351
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$1,713.99
Rate for Payer: AlohaCare Medicaid	$883.50
Rate for Payer: AlohaCare Medicare	$883.50
Rate for Payer: Cash Price	$1,148.55
Rate for Payer: Cash Price	$1,148.55
Rate for Payer: Devoted Health Medicare	$971.85
Rate for Payer: Hawaii Medical Service Association ABD	$279.09
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$883.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$380.02
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$1,501.95
Rate for Payer: Humana Medicare	$883.50
Rate for Payer: Kaiser Permanente Commercial	$1,590.30
Rate for Payer: Kaiser Permanente Medicaid	$901.17
Rate for Payer: Kaiser Permanente Medicare	$883.50
Rate for Payer: MDX Hawaii PPO	$1,713.99
Rate for Payer: Ohana Health Plan Medicaid	$883.50
Rate for Payer: Ohana Health Plan Medicare	$883.50
Rate for Payer: UnitedHealthcare Medicaid	$279.09
Rate for Payer: UnitedHealthcare Medicare	$883.50
Rate for Payer: University Health Alliance Commercial	$842.82

CT Angio Neck - Report

Professional

Both

$308.00

Service Code	HCPCS 70498 26
Hospital Charge Code	629771
Hospital Revenue Code	972
Min. Negotiated Rate	$81.64
Max. Negotiated Rate	$559.66
Rate for Payer: AlohaCare Medicaid	$187.99
Rate for Payer: AlohaCare Medicare	$81.64
Rate for Payer: Cash Price	$200.20
Rate for Payer: Cash Price	$200.20
Rate for Payer: Devoted Health Medicare	$89.80
Rate for Payer: Hawaii Medical Service Association Medicare	$81.64
Rate for Payer: Hawaii Western Management Group Commercial	$559.66
Rate for Payer: Health Management Network Commercial	$261.80
Rate for Payer: Kaiser Permanente Commercial	$89.80
Rate for Payer: Kaiser Permanente Medicaid	$89.80
Rate for Payer: Kaiser Permanente Medicare	$89.80
Rate for Payer: Ohana Health Plan Medicaid	$187.99
Rate for Payer: Ohana Health Plan Medicare	$81.64
Rate for Payer: UnitedHealthcare Medicaid	$187.99
Rate for Payer: UnitedHealthcare Medicare	$81.64

CT Angio Pelvis

Facility

$1,935.00

Service Code	HCPCS 72191
Hospital Charge Code	1167881
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$1,876.95
Rate for Payer: AlohaCare Medicaid	$967.50
Rate for Payer: AlohaCare Medicare	$967.50
Rate for Payer: Cash Price	$1,257.75
Rate for Payer: Cash Price	$1,257.75
Rate for Payer: Devoted Health Medicare	$1,064.25
Rate for Payer: Hawaii Medical Service Association ABD	$311.76
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$967.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$424.97
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$1,644.75
Rate for Payer: Humana Medicare	$967.50
Rate for Payer: Kaiser Permanente Commercial	$1,741.50
Rate for Payer: Kaiser Permanente Medicaid	$986.85
Rate for Payer: Kaiser Permanente Medicare	$967.50
Rate for Payer: MDX Hawaii PPO	$1,876.95
Rate for Payer: Ohana Health Plan Medicaid	$967.50
Rate for Payer: Ohana Health Plan Medicare	$967.50
Rate for Payer: UnitedHealthcare Medicaid	$311.76
Rate for Payer: UnitedHealthcare Medicare	$967.50
Rate for Payer: University Health Alliance Commercial	$850.50

CT Angio Pelvis

Facility

$1,935.00

Service Code	HCPCS 72191
Hospital Charge Code	1167881
Hospital Revenue Code	352
Min. Negotiated Rate	$1,644.75
Max. Negotiated Rate	$1,876.95
Rate for Payer: Cash Price	$1,257.75
Rate for Payer: Health Management Network Commercial	$1,644.75
Rate for Payer: Kaiser Permanente Commercial	$1,741.50
Rate for Payer: MDX Hawaii PPO	$1,876.95

CT Angio Pelvis - Report

Professional

Both

$355.00

Service Code	HCPCS 72191 26
Hospital Charge Code	629773
Hospital Revenue Code	972
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$598.59
Rate for Payer: AlohaCare Medicaid	$208.11
Rate for Payer: AlohaCare Medicare	$83.70
Rate for Payer: Cash Price	$230.75
Rate for Payer: Cash Price	$230.75
Rate for Payer: Devoted Health Medicare	$92.07
Rate for Payer: Hawaii Medical Service Association Medicare	$83.70
Rate for Payer: Hawaii Western Management Group Commercial	$598.59
Rate for Payer: Health Management Network Commercial	$301.75
Rate for Payer: Kaiser Permanente Commercial	$92.07
Rate for Payer: Kaiser Permanente Medicaid	$92.07
Rate for Payer: Kaiser Permanente Medicare	$92.07
Rate for Payer: Ohana Health Plan Medicaid	$208.11
Rate for Payer: Ohana Health Plan Medicare	$83.70
Rate for Payer: UnitedHealthcare Medicaid	$208.11
Rate for Payer: UnitedHealthcare Medicare	$83.70

Know your out-of-pocket cost for care.

All Charges