Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

CT Chest/Abdomen w/o Contrast

Facility

$4,747.00

Service Code	HCPCS 71250
Hospital Charge Code	8099513
Hospital Revenue Code	350
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$4,604.59
Rate for Payer: AlohaCare Medicaid	$2,373.50
Rate for Payer: AlohaCare Medicare	$2,373.50
Rate for Payer: Cash Price	$3,085.55
Rate for Payer: Cash Price	$3,085.55
Rate for Payer: Devoted Health Medicare	$2,610.85
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2,373.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$4,034.95
Rate for Payer: Humana Medicare	$2,373.50
Rate for Payer: Kaiser Permanente Commercial	$4,272.30
Rate for Payer: Kaiser Permanente Medicaid	$2,420.97
Rate for Payer: Kaiser Permanente Medicare	$2,373.50
Rate for Payer: MDX Hawaii PPO	$4,604.59
Rate for Payer: Ohana Health Plan Medicaid	$2,373.50
Rate for Payer: Ohana Health Plan Medicare	$2,373.50
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$2,373.50
Rate for Payer: University Health Alliance Commercial	$502.27

CT Chest/Abdomen w/o Contrast

Facility

$4,747.00

Service Code	HCPCS 71250
Hospital Charge Code	8099513
Hospital Revenue Code	350
Min. Negotiated Rate	$4,034.95
Max. Negotiated Rate	$4,604.59
Rate for Payer: Cash Price	$3,085.55
Rate for Payer: Health Management Network Commercial	$4,034.95
Rate for Payer: Kaiser Permanente Commercial	$4,272.30
Rate for Payer: MDX Hawaii PPO	$4,604.59

CT Chest/Abdomen w/o Contrast - Report

Professional

Both

$225.00

Service Code	HCPCS 71250 26
Hospital Charge Code	8099515
Hospital Revenue Code	972
Min. Negotiated Rate	$50.28
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicare	$50.28
Rate for Payer: AlohaCare Medicaid	$89.82
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Devoted Health Medicare	$55.31
Rate for Payer: Hawaii Medical Service Association Medicare	$50.28
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$55.31
Rate for Payer: Kaiser Permanente Medicaid	$55.31
Rate for Payer: Kaiser Permanente Medicare	$55.31
Rate for Payer: Ohana Health Plan Medicaid	$89.82
Rate for Payer: Ohana Health Plan Medicare	$50.28
Rate for Payer: UnitedHealthcare Medicaid	$89.82
Rate for Payer: UnitedHealthcare Medicare	$50.28

CT Chest/Abdomen w/ + w/o Contrast

Facility

$6,414.00

Service Code	HCPCS 71270
Hospital Charge Code	8099507
Hospital Revenue Code	352
Min. Negotiated Rate	$5,451.90
Max. Negotiated Rate	$6,221.58
Rate for Payer: Cash Price	$4,169.10
Rate for Payer: Health Management Network Commercial	$5,451.90
Rate for Payer: Kaiser Permanente Commercial	$5,772.60
Rate for Payer: MDX Hawaii PPO	$6,221.58

CT Chest/Abdomen w/ + w/o Contrast

Facility

$6,414.00

Service Code	HCPCS 71270
Hospital Charge Code	8099507
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$6,221.58
Rate for Payer: AlohaCare Medicaid	$3,207.00
Rate for Payer: AlohaCare Medicare	$3,207.00
Rate for Payer: Cash Price	$4,169.10
Rate for Payer: Cash Price	$4,169.10
Rate for Payer: Devoted Health Medicare	$3,527.70
Rate for Payer: Hawaii Medical Service Association ABD	$291.10
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,207.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$316.52
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$5,451.90
Rate for Payer: Humana Medicare	$3,207.00
Rate for Payer: Kaiser Permanente Commercial	$5,772.60
Rate for Payer: Kaiser Permanente Medicaid	$3,271.14
Rate for Payer: Kaiser Permanente Medicare	$3,207.00
Rate for Payer: MDX Hawaii PPO	$6,221.58
Rate for Payer: Ohana Health Plan Medicaid	$3,207.00
Rate for Payer: Ohana Health Plan Medicare	$3,207.00
Rate for Payer: UnitedHealthcare Medicaid	$291.10
Rate for Payer: UnitedHealthcare Medicare	$3,207.00
Rate for Payer: University Health Alliance Commercial	$799.87

CT Chest/Abdomen w/ + w/o Contrast - Report

Professional

Both

$335.00

Service Code	HCPCS 71270 26
Hospital Charge Code	8099509
Hospital Revenue Code	972
Min. Negotiated Rate	$58.43
Max. Negotiated Rate	$464.02
Rate for Payer: AlohaCare Medicaid	$133.95
Rate for Payer: AlohaCare Medicare	$58.43
Rate for Payer: Cash Price	$217.75
Rate for Payer: Cash Price	$217.75
Rate for Payer: Devoted Health Medicare	$64.27
Rate for Payer: Hawaii Medical Service Association Medicare	$58.43
Rate for Payer: Hawaii Western Management Group Commercial	$464.02
Rate for Payer: Health Management Network Commercial	$284.75
Rate for Payer: Kaiser Permanente Commercial	$64.27
Rate for Payer: Kaiser Permanente Medicaid	$64.27
Rate for Payer: Kaiser Permanente Medicare	$64.27
Rate for Payer: Ohana Health Plan Medicaid	$133.95
Rate for Payer: Ohana Health Plan Medicare	$58.43
Rate for Payer: UnitedHealthcare Medicaid	$133.95
Rate for Payer: UnitedHealthcare Medicare	$58.43

CT Chest High Resolution

Facility

$4,747.00

Service Code	HCPCS 71250
Hospital Charge Code	2424752
Hospital Revenue Code	352
Min. Negotiated Rate	$4,034.95
Max. Negotiated Rate	$4,604.59
Rate for Payer: Cash Price	$3,085.55
Rate for Payer: Health Management Network Commercial	$4,034.95
Rate for Payer: Kaiser Permanente Commercial	$4,272.30
Rate for Payer: MDX Hawaii PPO	$4,604.59

CT Chest High Resolution

Facility

$4,747.00

Service Code	HCPCS 71250
Hospital Charge Code	2424752
Hospital Revenue Code	352
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$4,604.59
Rate for Payer: AlohaCare Medicaid	$2,373.50
Rate for Payer: AlohaCare Medicare	$2,373.50
Rate for Payer: Cash Price	$3,085.55
Rate for Payer: Cash Price	$3,085.55
Rate for Payer: Devoted Health Medicare	$2,610.85
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$2,373.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$4,034.95
Rate for Payer: Humana Medicare	$2,373.50
Rate for Payer: Kaiser Permanente Commercial	$4,272.30
Rate for Payer: Kaiser Permanente Medicaid	$2,420.97
Rate for Payer: Kaiser Permanente Medicare	$2,373.50
Rate for Payer: MDX Hawaii PPO	$4,604.59
Rate for Payer: Ohana Health Plan Medicaid	$2,373.50
Rate for Payer: Ohana Health Plan Medicare	$2,373.50
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$2,373.50
Rate for Payer: University Health Alliance Commercial	$502.27

CT Chest High Resolution - Report

Professional

Both

$225.00

Service Code	HCPCS 71250 26
Hospital Charge Code	2424754
Hospital Revenue Code	972
Min. Negotiated Rate	$50.28
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$89.82
Rate for Payer: AlohaCare Medicare	$50.28
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Devoted Health Medicare	$55.31
Rate for Payer: Hawaii Medical Service Association Medicare	$50.28
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$55.31
Rate for Payer: Kaiser Permanente Medicaid	$55.31
Rate for Payer: Kaiser Permanente Medicare	$55.31
Rate for Payer: Ohana Health Plan Medicaid	$89.82
Rate for Payer: Ohana Health Plan Medicare	$50.28
Rate for Payer: UnitedHealthcare Medicaid	$89.82
Rate for Payer: UnitedHealthcare Medicare	$50.28

CT Chest w/ Contrast

Facility

$2,244.00

Service Code	HCPCS 71260
Hospital Charge Code	1168285
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$2,176.68
Rate for Payer: AlohaCare Medicaid	$1,122.00
Rate for Payer: AlohaCare Medicare	$1,122.00
Rate for Payer: Cash Price	$1,458.60
Rate for Payer: Cash Price	$1,458.60
Rate for Payer: Devoted Health Medicare	$1,234.20
Rate for Payer: Hawaii Medical Service Association ABD	$232.90
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,122.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$253.12
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$1,907.40
Rate for Payer: Humana Medicare	$1,122.00
Rate for Payer: Kaiser Permanente Commercial	$2,019.60
Rate for Payer: Kaiser Permanente Medicaid	$1,144.44
Rate for Payer: Kaiser Permanente Medicare	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,176.68
Rate for Payer: Ohana Health Plan Medicaid	$1,122.00
Rate for Payer: Ohana Health Plan Medicare	$1,122.00
Rate for Payer: UnitedHealthcare Medicaid	$232.90
Rate for Payer: UnitedHealthcare Medicare	$1,122.00
Rate for Payer: University Health Alliance Commercial	$686.18

CT Chest w/ Contrast

Facility

$2,244.00

Service Code	HCPCS 71260
Hospital Charge Code	1168285
Hospital Revenue Code	352
Min. Negotiated Rate	$1,907.40
Max. Negotiated Rate	$2,176.68
Rate for Payer: Cash Price	$1,458.60
Rate for Payer: Health Management Network Commercial	$1,907.40
Rate for Payer: Kaiser Permanente Commercial	$2,019.60
Rate for Payer: MDX Hawaii PPO	$2,176.68

CT Chest w/ Contrast - Report

Professional

Both

$226.00

Service Code	HCPCS 71260 26
Hospital Charge Code	629703
Hospital Revenue Code	972
Min. Negotiated Rate	$54.67
Max. Negotiated Rate	$378.67
Rate for Payer: AlohaCare Medicaid	$113.56
Rate for Payer: AlohaCare Medicare	$54.67
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$60.14
Rate for Payer: Hawaii Medical Service Association Medicare	$54.67
Rate for Payer: Hawaii Western Management Group Commercial	$378.67
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Kaiser Permanente Commercial	$60.14
Rate for Payer: Kaiser Permanente Medicaid	$60.14
Rate for Payer: Kaiser Permanente Medicare	$60.14
Rate for Payer: Ohana Health Plan Medicaid	$113.56
Rate for Payer: Ohana Health Plan Medicare	$54.67
Rate for Payer: UnitedHealthcare Medicaid	$113.56
Rate for Payer: UnitedHealthcare Medicare	$54.67

CT Chest w/o Contrast

Facility

$1,610.00

Service Code	HCPCS 71250
Hospital Charge Code	1168287
Hospital Revenue Code	352
Min. Negotiated Rate	$106.81
Max. Negotiated Rate	$1,561.70
Rate for Payer: AlohaCare Medicaid	$805.00
Rate for Payer: AlohaCare Medicare	$805.00
Rate for Payer: Cash Price	$1,046.50
Rate for Payer: Cash Price	$1,046.50
Rate for Payer: Devoted Health Medicare	$885.50
Rate for Payer: Hawaii Medical Service Association ABD	$194.84
Rate for Payer: Hawaii Medical Service Association Commercial	$133.51
Rate for Payer: Hawaii Medical Service Association Medicare	$805.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$211.43
Rate for Payer: Hawaii Western Management Group Commercial	$106.81
Rate for Payer: Health Management Network Commercial	$1,368.50
Rate for Payer: Humana Medicare	$805.00
Rate for Payer: Kaiser Permanente Commercial	$1,449.00
Rate for Payer: Kaiser Permanente Medicaid	$821.10
Rate for Payer: Kaiser Permanente Medicare	$805.00
Rate for Payer: MDX Hawaii PPO	$1,561.70
Rate for Payer: Ohana Health Plan Medicaid	$805.00
Rate for Payer: Ohana Health Plan Medicare	$805.00
Rate for Payer: UnitedHealthcare Medicaid	$194.84
Rate for Payer: UnitedHealthcare Medicare	$805.00
Rate for Payer: University Health Alliance Commercial	$502.27

CT Chest w/o Contrast

Facility

$1,610.00

Service Code	HCPCS 71250
Hospital Charge Code	1168287
Hospital Revenue Code	352
Min. Negotiated Rate	$1,368.50
Max. Negotiated Rate	$1,561.70
Rate for Payer: Cash Price	$1,046.50
Rate for Payer: Health Management Network Commercial	$1,368.50
Rate for Payer: Kaiser Permanente Commercial	$1,449.00
Rate for Payer: MDX Hawaii PPO	$1,561.70

CT Chest w/o Contrast - Report

Professional

Both

$186.00

Service Code	HCPCS 71250 26
Hospital Charge Code	629705
Hospital Revenue Code	972
Min. Negotiated Rate	$50.28
Max. Negotiated Rate	$322.87
Rate for Payer: AlohaCare Medicaid	$89.82
Rate for Payer: AlohaCare Medicare	$50.28
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Devoted Health Medicare	$55.31
Rate for Payer: Hawaii Medical Service Association Medicare	$50.28
Rate for Payer: Hawaii Western Management Group Commercial	$322.87
Rate for Payer: Health Management Network Commercial	$158.10
Rate for Payer: Kaiser Permanente Commercial	$55.31
Rate for Payer: Kaiser Permanente Medicaid	$55.31
Rate for Payer: Kaiser Permanente Medicare	$55.31
Rate for Payer: Ohana Health Plan Medicaid	$89.82
Rate for Payer: Ohana Health Plan Medicare	$50.28
Rate for Payer: UnitedHealthcare Medicaid	$89.82
Rate for Payer: UnitedHealthcare Medicare	$50.28

CT Chest w/ + w/o Contrast

Facility

$2,468.00

Service Code	HCPCS 71270
Hospital Charge Code	1168283
Hospital Revenue Code	352
Min. Negotiated Rate	$2,097.80
Max. Negotiated Rate	$2,393.96
Rate for Payer: Cash Price	$1,604.20
Rate for Payer: Health Management Network Commercial	$2,097.80
Rate for Payer: Kaiser Permanente Commercial	$2,221.20
Rate for Payer: MDX Hawaii PPO	$2,393.96

CT Chest w/ + w/o Contrast

Facility

$2,468.00

Service Code	HCPCS 71270
Hospital Charge Code	1168283
Hospital Revenue Code	352
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$2,393.96
Rate for Payer: AlohaCare Medicaid	$1,234.00
Rate for Payer: AlohaCare Medicare	$1,234.00
Rate for Payer: Cash Price	$1,604.20
Rate for Payer: Cash Price	$1,604.20
Rate for Payer: Devoted Health Medicare	$1,357.40
Rate for Payer: Hawaii Medical Service Association ABD	$291.10
Rate for Payer: Hawaii Medical Service Association Commercial	$224.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,234.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$316.52
Rate for Payer: Hawaii Western Management Group Commercial	$179.20
Rate for Payer: Health Management Network Commercial	$2,097.80
Rate for Payer: Humana Medicare	$1,234.00
Rate for Payer: Kaiser Permanente Commercial	$2,221.20
Rate for Payer: Kaiser Permanente Medicaid	$1,258.68
Rate for Payer: Kaiser Permanente Medicare	$1,234.00
Rate for Payer: MDX Hawaii PPO	$2,393.96
Rate for Payer: Ohana Health Plan Medicaid	$1,234.00
Rate for Payer: Ohana Health Plan Medicare	$1,234.00
Rate for Payer: UnitedHealthcare Medicaid	$291.10
Rate for Payer: UnitedHealthcare Medicare	$1,234.00
Rate for Payer: University Health Alliance Commercial	$799.87

CT Chest w/ + w/o Contrast - Report

Professional

Both

$238.00

Service Code	HCPCS 71270 26
Hospital Charge Code	629699
Hospital Revenue Code	972
Min. Negotiated Rate	$58.43
Max. Negotiated Rate	$464.02
Rate for Payer: AlohaCare Medicaid	$133.95
Rate for Payer: AlohaCare Medicare	$58.43
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$64.27
Rate for Payer: Hawaii Medical Service Association Medicare	$58.43
Rate for Payer: Hawaii Western Management Group Commercial	$464.02
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Kaiser Permanente Commercial	$64.27
Rate for Payer: Kaiser Permanente Medicaid	$64.27
Rate for Payer: Kaiser Permanente Medicare	$64.27
Rate for Payer: Ohana Health Plan Medicaid	$133.95
Rate for Payer: Ohana Health Plan Medicare	$58.43
Rate for Payer: UnitedHealthcare Medicaid	$133.95
Rate for Payer: UnitedHealthcare Medicare	$58.43

CT Drain Abscess or Cyst Soft Tissue

Facility

$2,402.00

Service Code	HCPCS 10030
Hospital Charge Code	8127561
Hospital Revenue Code	350
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,035.20
Rate for Payer: AlohaCare Medicaid	$1,201.00
Rate for Payer: AlohaCare Medicare	$1,201.00
Rate for Payer: Cash Price	$1,561.30
Rate for Payer: Cash Price	$1,561.30
Rate for Payer: Devoted Health Medicare	$1,321.10
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,389.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,201.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$2,281.90
Rate for Payer: Health Management Network Commercial	$2,041.70
Rate for Payer: Humana Medicare	$1,201.00
Rate for Payer: Kaiser Permanente Commercial	$2,161.80
Rate for Payer: Kaiser Permanente Medicaid	$1,225.02
Rate for Payer: Kaiser Permanente Medicare	$1,201.00
Rate for Payer: MDX Hawaii PPO	$2,329.94
Rate for Payer: Ohana Health Plan Medicaid	$1,201.00
Rate for Payer: Ohana Health Plan Medicare	$1,201.00
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,201.00
Rate for Payer: University Health Alliance Commercial	$4,035.20

CT Drain Abscess or Cyst Soft Tissue

Facility

$2,402.00

Service Code	HCPCS 10030
Hospital Charge Code	8127561
Hospital Revenue Code	350
Min. Negotiated Rate	$2,041.70
Max. Negotiated Rate	$2,329.94
Rate for Payer: Cash Price	$1,561.30
Rate for Payer: Health Management Network Commercial	$2,041.70
Rate for Payer: Kaiser Permanente Commercial	$2,161.80
Rate for Payer: MDX Hawaii PPO	$2,329.94

CT Drain Abscess or Cyst Soft Tissue - Report

Professional

Both

$986.00

Service Code	HCPCS 10030
Hospital Charge Code	8127563
Hospital Revenue Code	972
Min. Negotiated Rate	$115.65
Max. Negotiated Rate	$893.88
Rate for Payer: AlohaCare Medicaid	$132.13
Rate for Payer: AlohaCare Medicare	$115.65
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$127.22
Rate for Payer: Hawaii Medical Service Association ABD	$132.13
Rate for Payer: Hawaii Medical Service Association Commercial	$243.58
Rate for Payer: Hawaii Medical Service Association Medicare	$115.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$132.13
Rate for Payer: Hawaii Western Management Group Commercial	$893.88
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$127.22
Rate for Payer: Kaiser Permanente Medicaid	$127.22
Rate for Payer: Kaiser Permanente Medicare	$127.22
Rate for Payer: Ohana Health Plan Medicaid	$132.13
Rate for Payer: Ohana Health Plan Medicare	$115.65
Rate for Payer: UnitedHealthcare Medicaid	$132.13
Rate for Payer: UnitedHealthcare Medicare	$115.65
Rate for Payer: University Health Alliance Commercial	$160.00

CT Drain Per/Retr Fld w/Cath Perc

Facility

$13,913.00

Service Code	HCPCS 49407
Hospital Charge Code	2424758
Hospital Revenue Code	350
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,495.61
Rate for Payer: AlohaCare Medicaid	$6,956.50
Rate for Payer: AlohaCare Medicare	$6,956.50
Rate for Payer: Cash Price	$9,043.45
Rate for Payer: Cash Price	$9,043.45
Rate for Payer: Cash Price	$9,043.45
Rate for Payer: Devoted Health Medicare	$7,652.15
Rate for Payer: Hawaii Medical Service Association Commercial	$2,109.21
Rate for Payer: Hawaii Medical Service Association Medicare	$6,956.50
Rate for Payer: Hawaii Western Management Group Commercial	$13,217.35
Rate for Payer: Health Management Network Commercial	$11,826.05
Rate for Payer: Humana Medicare	$6,956.50
Rate for Payer: Kaiser Permanente Commercial	$12,521.70
Rate for Payer: Kaiser Permanente Medicaid	$7,095.63
Rate for Payer: Kaiser Permanente Medicare	$6,956.50
Rate for Payer: MDX Hawaii PPO	$13,495.61
Rate for Payer: Ohana Health Plan Medicaid	$6,956.50
Rate for Payer: Ohana Health Plan Medicare	$6,956.50
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,956.50
Rate for Payer: University Health Alliance Commercial	$10,141.19

CT Drain Per/Retr Fld w/Cath Perc

Facility

$13,913.00

Service Code	HCPCS 49407
Hospital Charge Code	2424758
Hospital Revenue Code	350
Min. Negotiated Rate	$11,826.05
Max. Negotiated Rate	$13,495.61
Rate for Payer: Cash Price	$9,043.45
Rate for Payer: Health Management Network Commercial	$11,826.05
Rate for Payer: Kaiser Permanente Commercial	$12,521.70
Rate for Payer: MDX Hawaii PPO	$13,495.61

CT Drain Per/Retr Fld w/Cath Perc - Report

Professional

Both

$2,299.00

Service Code	HCPCS 49407 26
Hospital Charge Code	2424760
Hospital Revenue Code	972
Min. Negotiated Rate	$199.39
Max. Negotiated Rate	$1,954.15
Rate for Payer: AlohaCare Medicaid	$199.39
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Cash Price	$1,494.35
Rate for Payer: Hawaii Medical Service Association ABD	$199.39
Rate for Payer: Hawaii Medical Service Association Commercial	$358.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$199.39
Rate for Payer: Hawaii Western Management Group Commercial	$834.60
Rate for Payer: Health Management Network Commercial	$1,954.15
Rate for Payer: Ohana Health Plan Medicaid	$199.39
Rate for Payer: UnitedHealthcare Medicaid	$199.39
Rate for Payer: University Health Alliance Commercial	$267.63

CT Drain Visceral Fluid w/Cath Perc

Facility

$1,234.00

Service Code	HCPCS 75989
Hospital Charge Code	1167986
Hospital Revenue Code	350
Min. Negotiated Rate	$103.94
Max. Negotiated Rate	$1,196.98
Rate for Payer: AlohaCare Medicaid	$617.00
Rate for Payer: AlohaCare Medicare	$617.00
Rate for Payer: Cash Price	$802.10
Rate for Payer: Cash Price	$802.10
Rate for Payer: Devoted Health Medicare	$678.70
Rate for Payer: Hawaii Medical Service Association ABD	$103.94
Rate for Payer: Hawaii Medical Service Association Medicare	$617.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$112.58
Rate for Payer: Hawaii Western Management Group Commercial	$1,172.30
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Humana Medicare	$617.00
Rate for Payer: Kaiser Permanente Commercial	$1,110.60
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: Kaiser Permanente Medicare	$617.00
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: Ohana Health Plan Medicaid	$617.00
Rate for Payer: Ohana Health Plan Medicare	$617.00
Rate for Payer: UnitedHealthcare Medicaid	$103.94
Rate for Payer: UnitedHealthcare Medicare	$617.00
Rate for Payer: University Health Alliance Commercial	$317.64

Know your out-of-pocket cost for care.

All Charges